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r da <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN CO@iTT PMLIC HEALTH SS84IC,S paj—'z <br /> E[VIHo%k1EffrAL RZALTH DITISION t <br /> 445 X SAN JOAQUIN, PEONS (209)468-34210 1 <br /> P O BOX 2009, STOCITM, CA 95201 �LCz Z 8 19 5 <br /> ' PERXIT EXPIRES1 YRARMgM DATE <br /> (COMPlete in Triplaaa-te) cNV1l�ONM�NT '��AL i <br /> App.:iaanian fa IIa=ebY made to a= J p�i�NATIS�RVIC�S <br /> cation La made is aagsrit; Caancy for a perait to conatr]et erd/or iaata;), the vary. heraix described_ =a <br /> ' APAu =mpAirtace rith Saar Joaquin Cot v r ordiaaace ao. 549 #=d 1862 aad the caules cad Regulatiaaa 4r San <br /> Joaquin Catrrtty Public Sealth Services. pp <br /> Job AQGtasi ] % City Lot 31so/Acreage jtLiginrnS <br /> ' Owner's Name �_ fi I 4t' d o Address iflrm -i hone i <br /> Corntractac �� Addrtss { Cult License NO6P��7�Phan <br /> ' TYPE OF WELL/PUMP- NEW WELL ❑ WELL Fl1:Pt.AC9&4e IT ❑ OESTRUC Tlom ❑ Out at service Vela ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR O OTHVF XC Q�¢ 1��F W� O <br /> DISTANCE TO NEAREST SfPT1C TANK �{ SEWER LINES OISFOSAL f1,D PflLtN „1Q~ f <br /> FOUNOATiON -- AGRICULTURE WELL OTHER WELL2L22�— PITS/SUMPS <br /> ' INTFNCED USE TYPE OF WELL PROSLEM AREA CONSTRUCTION SPFCIFIGA 1014`5 <br /> C1 InCustsrai ❑ OMnt Bottom © Manteca Me. of Well EX-Ary t n 77 012- at W04 Castng <br /> rl 0an+aauclPmote C Gravel Pads ❑ Tracy Type of Casing Soamricatio <br /> i"i Public 'W0tetar �t7elta O"th of Grout Seal Type of Grou I he ;t <br /> ' I i Ifr,patson Wfwppno: Oopth #Eastarrt Seal lruta"et by <br /> Repaw• Work Oona f3 Tww of Pump � H P � epth~ tats Work Doe <br /> " In <br /> Wei! Otra�arh @ Welt O�mtheter �a6 7bterial D <br /> ' 0evat tiller uazerisl It Depth L� <br /> TYP>: Of SEPTIC WORK NEW INSTALLATION 1 I REPAIRIAOUiTION I I OESTRUCTION 111Na Sep(tC system asrmitted if public iwwer is <br /> avadwe mthut 200 feet.) <br /> Instaliatwn Wdl arms F19OK e M CaaWMsnctak Other <br /> NunOw of kWmq truants: Number of bednmam <br /> Charaatatr at spd to a depth of 3 test: Water tants depth_ J <br /> SEPTIC TANK a Type/Rditi _ Caoaaty Info. Compsrmnants 1 _ <br /> AXG. EATMI@IT PLT-❑ Method at Duoosal _ a o O <br /> ' Okmnm r4 emwevc WOO rrau dattan Prnparty Line <br /> a. <br /> LEACHING UNG 0 Na & Lengdt of Ines Toms /=e Lo <br /> length 2 <br /> ' PLTER 860 ❑ Ctatanaa to mmwm t_ Wed Foundaaan property Lute <br /> V1 <br /> a <br /> SUPAGE PSIS 11 Clown Site Nambes o a rd x <br /> c.to <br /> SUMPS �� LT Owtan *mm= WOO Fonrrsdavw Ptotsarty Una E � ta' <br /> ' DISPOSAL PONDS 0 <br /> COMIN tnims and oes hmm*n oared apand that the worst will be done az accef wwa win co <br /> ith San Joaquin ordr <br /> a# U*Sam Joaquin catarw <br /> Norte owner or raarmd agwws m9paiwo ceitfia t the follawmil:"I cwmy that in the perfomnenea oftha wane far wmeh tlt+s per <br /> ' ompicy any pwwn3-aueh rtgnner as to bs¢onw aubpa to workmen's Compensation!awe of Cahfonm.”ConuacW s ranng or sa <br /> Qw lkw me fGltt +1 cwofY that urs tea oulormanea at ilea wart for winch thin yertM Jit WmJed.1 and!smpkzY Ae�s wblret a c� U <br /> cc <br /> T4 <br /> Tho =0 for m mqunrad � Co drawrrm an a warsa side � <br /> S4,ad TltfeC �ar4 <br /> (�l�M Yy) FOR OEPARTrMeWr USIE ONLY <br /> t Q a x <br /> AMhca0an Accept"by Onto_ "+ ' �b��l+ Anes <br /> ' P4t or Grout Inspreaea 4y Data F-mal Inspections by Oats <br /> AOdmi1emal C*rn nanm <br /> ' ApyJ.lcsgt - RetUrZ 211 cataiea ta- San JoaquxA County Pnblio Health Sery;tea <br /> Sav% omental aaalttt Perak/BarvZcea <br /> 445 N San Joaquin. P O Sex 2009, Stkn, CA 95201 <br /> AMOUNT OtJE InrrtptllrT ABI�M1I;TEO F—Asr Re=VeD e3Y OATS PeR ]ua <br /> TOTAL P 01 <br />