|
ima Coulmllc srvl win
<br /> '`,•�- Cili, ,VR
<br /> La tllse Creade
<br /> i��•. .� lob Address / � � :: !•r':
<br /> • ::.',i•,'_.Ir ' iE(]{;1 .Addleaa `r GSA !�r>`1a1 �.9�r1®hOM
<br /> Ownei a Name ^:
<br /> Conttlttor Addrest e r_ �.r. 1 Ittnit No.6Z3_
<br /> Phone
<br /> WELL REPLACEMENT fl OESTAUCTIOH t Or Barrlca Well
<br /> s`' p:a"•:�;':i:, i TYPE OF WELLIPUMP: NEW WILL ❑ SYSTEM REPAIR Cl OTHER ❑ Wnitoring Volt
<br /> PUMP INSTALLATION ❑ ,
<br /> _ DISPOSAL FID. PROP.LINE � .
<br /> :,-i}�;4.,.,, r ~•' � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES
<br /> AGRICULTURE WELL OTHEA WELL PiTSISUMPS
<br /> FOUNDATION
<br /> INTENDED USE TYPE OF Will PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> `}H....• r Tyr r
<br /> Cl lndutlnsl C]Open Bottom ❑M►nuca Du.al W6N E■cavation_ Dia. of Wap Casing
<br /> , T al Caaina �... Speuticalrons
<br /> Lir C.I Ooniauk7Pllvasa Cl Gavel Pec► ❑Tiacy Two
<br /> f r I'I PubUc Il Other fl Dtlu of Grout 5681 Typo of Grout-
<br /> 0491h _, [[
<br /> I I In atwn T Approa.Depth f L Estlan Sur}au Sael Inualsad by sty o
<br /> }>;'i s,-7 W and-_-- H.p. Stale Work DoH f
<br /> irS Y l
<br /> Repair Worts Dant 0 Type of Pump
<br /> fy{,,,+r ` K
<br /> Boating Materlalf, Depth,JSntL..�..rrs
<br /> '15u.
<br /> n +1, •`t" WN Dtfttuctitxl Wall Diertseler _..,$.
<br /> ;s �'�rp p r Filter Hi►Ur1a1 a Depth I lr tl evert — + S 4
<br /> ; 1 ti 4,1'. Depth
<br /> rr'' •a5.r. 1
<br /> tikvtirs ,y., + c TYPE OF SEPTrC WORK: HEW INSTAIt�1T10N t L REPAIRfADDITION L I pfSTRUCiION L i IN*uptc ayuam permluad if p1 Lfc'sawar Ia Q .
<br /> k` _ avadab4o wilh:n 200 LMI.1 .�1 k 'fir':.
<br /> x'k{xy t t{ ;' �' IMi1Na0bn will aarrv: RstWonu Cormsrlc 11_ O[Mt
<br /> Nurnbw of Ilvina Units: Number of bedrooms
<br /> rY ►ra i Water table daplh
<br /> ChNutw of cull to a"path of 3 lael: 1• y� ?
<br /> Capacity No.Compartmtnfa ;e ,
<br /> SEPTIC TANK ❑ Type/Mlp
<br /> PKO.TREATMENT PLT.Cl Method of Dypaul 4 ; ;
<br /> ��4.-.1-,: plusnca to rsasrwt: Woo Foundaliori Properly Lina
<br /> +��,rs'�:5{:2?'1_w.may:`:?'• s .y:::G: .�-
<br /> `,�3��A.
<br /> LEACHING LINE L) No,A Lanath of Fines —_ Tout langth/site
<br /> s
<br /> �fgr ri . FILTER SED Ca Dbla,.ce to nearest: WeN Foundation PIowRY Lina
<br /> SEEPAGE PITS I I Qapth - Sae ,,Number 'ir• C
<br /> a} rt r SUA1P8 LI DEturra to Man►t: Wstl founefatan ProWny Lina q
<br /> . �.* DISPOSAL PONDS ❑ .
<br /> I hareby cs& that 1 hn6 prepared'this application end Thal the work will tsa done in accordance wish San Joaqulr,cc,unty ordinances,alata laws,and
<br /> :. {=• a!••�s:, :;,r' rula6 seat:pulaLiom of Ina San Jaaquin cwctr
<br /> Name&mrer or bctnead egant's sig"WI&caidrat Ihvs folsowina:"I Nrtity that in t:N par}ormanu cf the rrorY tar r:hich tfit;+arre-it is iaauad,1 shall rrls 3
<br />'' a,``•'"' ;;,'�•;,`::' ', ampwy any pareo+s h wch rnanrstr a■to Dacorry wbpet to workman's ccrnponsation laws of Cal,lorrue,"Contleclots hirir,0 or vel:cantnctinp rliaMlura
<br /> +�
<br /> t:artitraa the fosowina:"L certify that in lha performarlee of the work for which this permll is itaued.I shall amtaoy persona subl6ct to wpr:rnari a cor.;,nae- '
<br /> j
<br /> ti:.r.Owe d GkfomFa."
<br /> The applicant mwl csN Lor/N tequirod inaptctfons.Comp[tle dravrina on raverN side.
<br /> �j r
<br /> 3'.•dyt.'!Cs tTi � i '�.Y` QY1�3,
<br /> Title.,
<br /> _ Data: . f--e''-`--_'— ., ►-.� ,.
<br /> OR DEPARTMENT USE ONLY -
<br /> s1-4 k AppikatSan AeeapteG by
<br /> Dar
<br /> 4 aI.
<br /> � 11Y ft 1 f . DS
<br /> Pi:or Glom lmwtion byr Dale Final InlpeFtion by / r f
<br /> + Additnwi`fansttsersU Y n
<br /> t
<br /> ADDllcan• Hatura all'coplaa to 'SRA Joaqula'CouatY put•llc Ilealth:8arvicea
<br /> SarLroaneatal Health permit/Servlcea
<br /> -Slab It 11an Jaaqul0.: P 0 Box 8009, Stkn, CA 95201.
<br /> FE[ ;,:." AMDUNTItEMIT7ED - UK IN
<br /> ,RLCEIVEG dY -DAVE `PFRIA[T'HO. _ iL 6ryf{ t
<br /> INFO AstDUMT DUE CAStI
<br /> E i
<br /> � �,¢!.'t1 ) :eH l>EN taIV sr�1r '"��; �' tit t°�`��e;r•' tL,
<br /> r ctr`,i��;`�'rs `4 r - 1 t,••; ;t�'�y�l��j["i'a�U'`�tLt�'..:.�4.-.twvan.rrS.iwa+l.:,r:,yaia=: st::,'�:s;r��sti:;<:��,:lx�;r.-�„��:i�- t>r.+s::�e::w� � •1 fl��p+`�� :�
<br /> 1
<br />
|