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APPLICATION FOR PE;�'.' <br /> Telephone (209) 6( 67131 MATE ISSUED - <br /> PE MIT EXPIRES 1 LIAR tRO DATISSUED <br /> (Complete in Triplicate( <br /> :.an as herel33' to the an..Joaquin t ' ror a permit to ronstr+,act and/or install tate w.r�k harein <br /> :` taunt „ for sewage or Mme. 1862 far well <br /> Iced. This apl Lca:tif is.ode in ccxr�pl is y <br /> nF9 a.La Rs,les t Yx #L �,lations.of the Slim Joapui H a.^.r, tri t. <br /> Subd r s Bon ria Phane <br /> l � n� Ad d r?e'S' <br /> . <br /> .... Phone <br /> ,wirerose Nq. . <br /> ?Ft LiPump Wt1 lCs: NEW'WELL TELL REPLACEMENT DESS <br /> P IHSTALLATs ,,��� °`TEM6 NEPAIR � ' ' <br /> r TO NEAREST SEf►TIC TANK ES 17ISa _ PROP. LINE <br /> DIW _ � - C <br /> FOUNDATION �_..._...T�. <br /> �. ;RE WELL �� AHC �.PITSl5 S <br /> � �. <br /> o USE TYPE OF WELL i 163 <br /> c <br /> If uStr~i l 0.00011,Eottbm <br /> Domestic0rivate [j Gravel :Pack <br /> Public .Other E]Delta type of Casing <br /> l.M.i irwigation Approx. Eastern specifications <br /> D Cathodic Protection Depth <br /> Depth of I(rcat Seat <br /> GeophysicaI Type of Grout <br /> Other Surface Seal Installed b <br /> ' State Bork Done,"U <br /> Repair Work tie Type ofPumpM.P. �- <br /> Wel I Destruction EJ Well Diameter .�_Seal inn Material (top 50') <br /> Depth Filler Material Below SC}` <br /> TYPE OF SLPTTC WORK: NEW INSTALLATION[—J REPAIRIADDITION [D (No septic tank or seepage pit <br /> av able if public <br /> hin 200 fs ewer is <br /> Installation will serve. Residence— Comerc Comeri a I ether <br /> Number of living units. Wirer of bedrooms � Lot size <br /> Character of soil to a depth of 3 Feet; !dater table depth <br /> SEPTIC 'TANK Type/Mfg Capacity No. compartinents <br /> PKG. TREATKENT PLT. Type Mfg Capacity _ Method of Disposal <br /> SEWAGE SYSTi I. . Distance.to near es€: dell _ w � Foundation . w property Litae.. ��� , <br /> DESTW <br /> NE U Teal length/size ..... <br /> LEACHING LTt# ib=.8 Lersgth of lines ,.,�.� <br /> rl-LIER PEO 0 . DistanCe to OftrAst' tieTl 1 .c.,' o y Line <br /> Size, <br /> Distance to nearest. Well foundation Property Line <br /> C9ISP�1'.AL PiS ......... <br /> 1 hev, hr certify thin:i have prepared,this appii ," Ion and that the work will be alone in +: dance i�ith.San Joaquin county <br /> Y ��wata 1a , and rules ari �;,a��'t, �= the Salt Joaquin Local Health Distr <br /> ;,. or..liCeoseit a is signeitaq r _, he following- ""�I certify that 111 t!t :Arte of the workfor w�.ich this <br /> isiuft I :sha1I net:employ an suth mangier as to become subject to { , s c satian Saws of ealifar hic <br /> Urs hiring ar sub�cantr8ctisig rtifies the following: ""I certify t, ". he perfc»vnatrte of the work fast which <br /> rrssit i issued'.,. t.sh411 employ " " : ,,` ;t to workmen's compensation �;: . .. California-" <br /> plirant must a 11 far S11required ���=i Cts flete drawing on reu sasfe, <br /> t Dater-I�*4 � <br /> Title: <br /> Applitation y � � Area <br /> Addition 0 L.gldi 69- 6 <br /> Pit car !late Manteca 823-1104 <br /> Pini' rn by s w Gate . _ 0 Tracy 835-6:385 <br /> Ave. P.O. Box 2 �� Stk.,, GA 95201 <br /> Applicant xalrn all copie to, +avrr°tar,,F,erltal Health Perarrit/Services 1602 E. Hazeltaxn , <br /> -. <br /> EEC BASE AMOUNT DUE AMOUNT REMITTED RE EIVED BY RATE PERMIT <br /> i <br /> 1 182 SISI <br /> Eli I3-2e REV. 10/82 <br /> . 14 <br />