|
�Y
<br /> F
<br /> x
<br /> API'LICATION FOR i%'i dIT a
<br /> SAN JOAQUIN COUNTY pUBLIC 11FALT11 SERVICES
<br /> F,-jVIH0N1dFNTA1, ELEALTU I)IVISION prl:[2I7{. ;,t,�,rJIALHEAI.IH
<br /> 11A!}•LT0N AVE. . PHONE (209)468-39 WAIT r5k �'Vi! k.5
<br /> p O ISOX 200'9, sTOC:KTO N, CA 95201
<br /> t YI Lt '�tETtd _ JS1ik�
<br /> (Complete in Trlpli.cate)
<br /> ln
<br /> Applleatton la hereby r ae. i t95anul
<br /> t, C. nt �oi-
<br /> nn Lyr r,rdlnence No. W; and`1862 endInstal theekulee ande Re,Nletlore4'tt r San`
<br /> rpplicatlon is Ira:e in ccsl erten v
<br /> ,Fosquin coun_/�/t�yy Puhlle IIfeeeyllth SSer"'ces.
<br /> Jeb Address 1__ -�-�—
<br /> nC ll_I`�t.�+'^ ,�J Ac�,1rt15ti 1.-1 ��.-�•. t�Lrl l. � _ Ph.,nu
<br /> Owncl's h!ama _- I
<br /> kk "7� (}'1� ,,'} y} 7r R,^C�1CJL',+ t�_License No. nnre
<br /> Conllacter\ r >~y_� --'fir Add;esc - 1.1 ryW_�_'.. . 1 -
<br /> WELL R£FLACLI.IENT !• OE51RUCr10N I.i Out of Service Well
<br /> TYPE OF WELL/PUMP ,VEW WELL L.I. `� OTHER C monitoring Well I:7
<br /> -- PUMP INSTALLATION C3 ,« Tf%j REPAIR X
<br /> _ DISPOSAL FLD. PRO?, LINE
<br /> SEWER LINTS - .. PITS/SUMPS
<br /> '
<br /> DISTANCE TO NEAREST: SEPTIC TpNY. �_ y _ htER WELL
<br /> ..-.—�� FOUNDAI'JON ,••—�_—. AGRICULTVRE\".ELL_ _-C��__-- --
<br /> iNTEND_ED USE IYPz OF WELL PROBLf%l AFIEJ% COraSTRUCI10N SPECIFICATIONS Dia of Well casing
<br /> C7 OPen gonpm i I Manteca Dra of Well F.kcevetmn -__.__K--
<br /> i I Indur'lnel Spec,hcaoons ,
<br /> {? T,i,cv 1 ue 0 Cas-ng
<br /> L I Domas[rclPnvete i_1 Gravel Pack TT e of Groul�El!1R
<br /> Puhirc
<br /> 11 Other t' Duda Depth nl Cr�,ul Seal ..�..L�O�— Yp
<br /> Nl.tjdhcn -_-
<br /> Approx. Daprh I l:astarn Sur++l��eco Snal Inyldllad!,N
<br /> li v ESQ Slate Work Donn_ T"+t
<br /> x Avoeir Work Done CJ Type of Pump t 1(�_ _ ��
<br /> 851�� Sealjng 14
<br /> g s:er!nl � i+epih SIJ.
<br /> 'Nell Destruction ❑ Well D+emetaf Filler !taterlal i Depth
<br /> Depth i��-.••--- - -r nl ilea.I Public su-er.5
<br /> ;YPE OF 5EPTiC WORK, EIEvY W.;TALLATICIN I i REPAIRIAUUITILN D£SIPUCTION 1 I aval'abialwih,n 20G'•;et.i
<br /> Other
<br /> Installation will serve: nesidence_ Cammofciul_.-_ S
<br /> Number of iiving units: . Number of bedrooms -- �—Water table daPih
<br /> Ctraracidf of soil to a depth of 3 teat: -- CapaGltk. No. COmparih'Cnt7
<br /> s SEPTIC TANK 0 Type/Mfg - Method of DisPasel
<br /> PY.G,TREATMENT PLT.CI Properly Line
<br /> Distance to nearest: Well Foundation
<br /> _�-- Tota:lemU*h/site._
<br /> LEACHING LINE LI No.&Length of lires
<br /> PloPerlY LineFILTER BED C1 Distance to nearest: WeII Foundation
<br /> �- Numner
<br /> SEEPAGE PITS 11 Depth __....—See
<br /> SUMPS
<br /> 1.1 Distance to naeresl'. well _,-- roundal,on _ Property Line
<br /> DISPOSAL PONDS C7
<br /> I harehy Cerily that 1 have prePrcil this nPphcauon and Ill'" [he-,31k will oe done In accordance with San JOAtwin counly o0inancas,stale laws. anti
<br /> ruler and regulations of the San Joaquin County
<br /> Jame owner ar licensed aganPt siVnalurtl 4nrt1`iyS the fOtiors�nit "1 Ser[ify that In he performance of the work fat which this perm.[is Issued,S shag not
<br /> employ any Pers in such manner is to bnCOma Wblect 10 wurk men's cormdnsat.on law!of Catilol nia"CO n1raC1'1f S h:rino or•JUh[On!7sC UrtfJ Fgnt:ure
<br /> certif6os the IOIL wi g:"I certify that il,Ilia performance of the work for which this porm-t is ilsuad,l shall a nploy persons svbiec[To wO,Lma+i s COmVanla
<br /> tion lake ia.'
<br /> i N d The apPlic rt st cell for Oil 1er, od inxpe ti�tmplcln drawingo.. v ! side.
<br /> J
<br /> — , u l/
<br /> Title.. 41r:2.._�_
<br /> Signed X— U
<br /> ,rFOR OEPAll MENT USE ONLY —
<br /> f/' Dats.� _, Anna
<br /> Application Acceptsd by ... .�- .�. e a
<br /> Data FInellnaoecuon by Dale
<br /> Pit or Groue lnepei:Oon by �— r
<br /> Additions[Comments:
<br /> Appllce.nt - Return all coplea to: ServSeea• E�vl oc»eaqlltn County ntal111ee1thtrermlt/Servlcea
<br /> I'i01 E. liaxelton Ave., P C pox 2009. Stockton, CA
<br /> tt 95201
<br /> CK i!Ef,E,VED BY -I DwiE yERMI� 1 ND. _
<br /> p FEE AMOUNT DUE AMOUNT nEtiu-f_I L�OI`r Cq5•��^^ `
<br /> INF
<br /> L
<br /> ,1 r
<br /> IREV
<br />
|