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FIL E <br /> :iAN .lUnt,2i11N COUNTY PUBLIC IiEALT1f SERVICES Copy <br /> FNV I1f0NMFNTAL HEALTH DI <br /> ,Y :;AN .IOAQUIN, PHONE (20 ) 420 <br /> f' i) f3UX 2009, STOCKTON, <br /> 1'Ei{M1 T h_X��IItf1 YEAR <br /> (I'Ornialetf' in Tr3plic � A <br /> +i- .:��'•::•� !e h,-r-" mode to Sen Jcrqusc Cr:un•y far a ptrm:t to tonatruet a dl V. <br /> the work berate defer a <br /> mute In c T11anCr with sen .Inequiri cc,unty ominanct Mo. S40 rIE the Rules sod RMIYlatiana of SA <br /> C�-rt.y F*.:hilc Health Service@. <br /> r: adq=ett 21657 F. DoddS Rd_ �__ C,rv. i$CaX(�RL Loc Sist/Acreu6e. <br /> Dave Price A,tn•ets 21 657 }'.. — kr + .Jl<7rla� 't' ,1�I1.. Phone, <br /> ,lriarviance <br /> Y <br /> Driliers�ddfl�saP,Q.Box 64-ild—n—d-e-n—Lrcrsr14c. _Pr+o++tB. Z-3554 <br /> L Dr tivEtL'PUMP NEW WELL WELL REPLACEMENT r) . DESTRUCTION Ct out of Service Well <br /> PUMP INSTALLATION SYSTEM REPAIR 3t OTHER 0 Mlotiltorins Well [1FP : ., <br /> DISTANCE TO N£AA£ST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP.LINE <br /> _ FOUNDATION ` AGgtCULTURE WELL OTHER WELL PIYSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAYIONS k r <br /> ��Cusrnel ❑Open Bonom Ci Manteca Dia.of Wen Esewafion?^,._ Dy of Wen <br /> Casing <br /> f umesr erpr yeti `}Gr"Pack ('I Tracy Type of Casing»' steel 5peedieationf :..+.�.���......._ <br /> a ole I'1 Orr+er IZ pelta Depth of Grout Seat 50 Type of Grpu 9sac sandI emen d d <br /> a Iv„Huron _... Appros, h LI Eastern Surface Sero Insf~by <br /> Repa r Work Done Yi Type of Pump H.P, Slat•waft pone rgpair well <br /> Well Dastructwn ❑1_ We”Outer Selling Material A Depth <br /> S <br /> Depth Filler laterleil L Depth _ r <br /> `y"E 41' 5EPTfC WORK: NEW INSTALLATION I I RE PA ORIADOITION 1 I DESTRUCTION I I INS aep11C System parmrlted it public sewer es . <br /> available vnthin 200 fm.l 1 <br /> e, <br /> '�stsllation win wnrr Residence— Commarciaf Orhsr <br /> ffumb«of kwrng linins: Number of o}Dadrooms - <br /> Cheracter of$af to•depth of 3 het: Water UINIGEMbv <br /> SEPTIC TANK 0 Typo/Mfg Capacity.-- NMOIdt, <br /> PKG. TREATMENT PLT,C7 <br /> Distance to dearest: Wen Kotl�eion P►opereySERVICES fv� <br /> LEACHING LINE Ll No.A length of lines Toth!kongth/ <br /> FILTER BED n Distance to nearest: wan Foundation—_ Pt'ooerlY tient F <br /> SEEPAGE PITS I ! Depth Srra- Nlrrrlbfs <br /> SUMPS LI Oiaurin to naarrst: Wan Foundation Peopet— Lira <br /> DISPOSAL PONDS 0 <br /> I Mrebv MAIN that I he"propared thin appMearior+and that the work VAIbe det,re in OccOmW"with San JoegWn county urdirmairim.flee 4era;end <br /> rules end Iegulatrpna of the San Joaquin County <br /> Home owner or licensed agant'e signalure certifip the fokorwmg: 111 certi}v that in"Sotomintce of Ve-**^too wRlieh this perrnil N issued.1 Hletl not .� <br /> emPloY any person wl <br /> in such nner as to become subject to wo+kman't eorrQenfatiln lawn of California."CaMacWs hiring er tblapDntfalelaq fignetWe i <br /> Cenifias the following:"I CO"ItY that in the performance of the work for VWCh this permit is issued.1 s employ pereane Sub to tMorknlMl'S tonlPMlasi <br /> tion tows D} ilanla." . <br /> The ap ant Tor Im inspections.Complete drawing on nwerfe Title. <br /> Srpned X a TOW Corporate Secretary Dam! 1/31/94 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accaoted by Date Arse . <br /> P't or Grout Inspection b Date POW 1004 eedml by DOW77 <br /> Addmonsl commertls' fL �4 eaJp-_. <br /> npnl lr-1 - llr.,,rrn a]I rpP]n. tr: Sen .Inequln County Public ROf1th SorvlrrrR4370 —s T <br /> Snvt renq .1 Health 111,,* 2009. torr Q40 d0� 0 f <br /> Aad rr lien .rnAquln, P D hnx X004, iatkn, CAA 3 "�� 7P?6C <br /> rtE AMOUNT DU! AMOUNT R(MITTIP Itic"D SY DATE PfArAft'ta0. e k <br /> _ [ASN. F <br /> 133 X <br /> 9 <br /> i <br />