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_____ ___ 07-05-1994 G4:06PM FROM TO 1.3833404 P.01 `r APPLICATION CAT I ON - t � � 1� SAN JOAQUIN COUNTY PUBLIC HEALTH SER I1 ENVIRONMENTAL HEALTH DIVISION ND # 445 N SAN JOAQUIN, PHONE (209)468-3 f P O HCX 2009, STOCKTON, CA 95201 FiAC# PERHIT: EXPIREO I YRAR FRQM DATE ISS V # (Complete in Triplicate) App]ication;�is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This application;is made iCCW2ianct with $ajp doaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 1, Job Address I Y City S40CtC.+fxA Lot SiaP/Acreage AJIA /PVC S4A1n1 ue140r. -A/DO Owner'& Name Y Address �l?iLf i�P@ Phone !b 930 a/D Po &x Aq-31 r Contfactor� Address�Q_ �' fj �t.0 9574! License No, 72/z>L Phone TYPE OF WELL/PUMP: �' NEW WELL M WELL REPLACEMENT -7 DESTRUCTION 0 Dut of Service We11 Q PUMP INSTALLATION C SYSTEM REPAIR C� OTHER 0 Monitoring Well DISTANCE TO NEAREST.I SEPTIC TAMC SEWER LINES _ DISPOSAL FLD,_ PROP. LINE j FOUNDATION AGRICULTURE WELL -. O.THER.WELL_ PITS/SUMPS fNTeND€D USE TYPE OF WELL PRO13LCMAREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom ❑:Manteca Dia, of Well Excavation Dia, of Well Casing !� fl DernesticJPrivare ILI Gravel Pack- ZlTracy Type of Casing–kk4r) Pte- specifications n2!'-c 41 .11,2nA I'I Public Other NIO!lf7b9IhlCr M Deka Depth of Grout Seal ._ . ! Type of Groutdgnq��Je OL I i Irrigation -- Approx. Depth I l:Eastern Surface Seed Installed by _ Repair Work Done 0 type of Pump — R H.P. _� State Work Oona Well Destruction ❑ N0 Diameter Sealing ltsterial & Depth pth Filler Material & Aeptb 0 r { _? TYPE OF SEPTIC WORK; NEW INSTALLATION I I' REPAIR/ADO(TION I I DESTRUCTION I I (No Septic system permitted if Public we it available within 2W feet,I stallatinn will serve_ esidence_ Commercial,�,,,,_ Other Number of living units. Number of bedrooms Character of soil to a de th of 3 levet: Water table depth L, SEPTIC TAMC J�J Type /Mfg P#cG, TREATMENT PLT. Lf Rost brand fax transmittal me Distance to nearest. Well m4 76`7'1 sof pages . TO From LEACHING LINE -I No. & Length of lines Co. FILTER BED ❑ Distance to nearest; WeII E Dept. Phone# SEEPAGE PITS I Depth Sire Fax 5 Fex Y SUMPS L Distance to nearest: Wel :. DISPOSAL PONDS f� - - I :-'I hsreby Certify€that JI have repared thio.:application and that-the.work will be(tone in accordance with San Joaquin county ordinances, mate laws, and strias and:ragutetions at t San Joaquin county Homeowner ar ficensed:ag nt's iignatura certifies the following. "I certify that Inrhe pattorrnance of the.,work,tor which'•lhis permit is Issued, 1hall not 1 :.z employ any parson iri such nner as to became subject to workman's compensation laws of;California.".ConrraCtor&hiring or sub,-contracting Signature certfties the following: "I CO ify that in the performance of the work lor which this permit is issued, I&half employ persons subject to-workman'a compensa- ':z1 ion laws of Callfornla-" i The applicant must call for I required inspections. Complete drawing on reverse side. &j,W.Xrwiji 1 I Signed I1 41," Title: Date' DEPARTMENT USE ONLY *ppikedon ACGeptk by Date + Area 411:or Grout Impaction by gate Final inspection b Date rfonel Comfrtenes: ., : ;: f" App1`iCant Return all copies_to San Jogquiv County public health5ervjCBs tnvironmental Health .Permit/Services e t� 995 x San Joaquin, P O t34x 2409, 6Ckn, CA 3520I > FEC _ INFO AMOUNT drJE AMOUNT REMITTED CASH RECEIVED Sy DATE J[r�-.41' T rG1 L1) /i l' (,., _/ �{/J r dr J �•P�f+p�M11"Nd. teEY.r/n 51 V f•W ! p 1! I l�`]� � tri + ftll I P !