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APPLICATION FOR PEM I T SAN XAQUIN COMITY PIMLIC HEALTH VVICES ENVIBOPUNITAL HEALTH DIVISION 3503VTg 445 N SAN JOAQUIN, PEONS (209)488-3420 P 0 HOZ 2009, STOCKTON, CA 95201 PSBitIT EXPtM , YEAR FROM DATS TjQUEQ AUC 0 5 1993 (Complete in Triplicate) Application is hereby ands to tan Joaquin Come" for a permit to construct and/or instal,; the von �' This applionac tion is rade in c0RPliae with San Joaquin County Ordinance No. 549 and LW and the " ;r it. Joaquin County Public Bsalth services. Job Ada«s 11 -15 8eS31 PP AI/c City TrQ C- Lot Size/Acrease 140'-s so' Owner's None R a 6:to C er d e ll a Address Iq F_ . 3"d 5 L,Tr x c Ph., 0q) 975-11M 37 Contract t Address License No. Pq 7r9 Phare TYPE OF WELL/PMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION C1 Cut d u PUMP INSTALLATION a O SYSTEM PEPAIA O OTHER O Monitoring hall DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40 DISPOSAL FLO.44— PROP. LINE _0 FOUNDATION . 1"Q_r„ AGRICULTURE WELL -,1,a_ OTHER WELL 10 PITS/SUMPS INTENDED USE TYPE OF WELL PRO5LEM AREA CONSTRUCTION SPECIFICATIONS Ll Indusenal O Open sonom O Manteca Din. of WsA Excavation Die. of WON Casing Z Si Oomestic/Private O Gravel Paw OtTracy Type of Casing QV C- Specifications �t 1.1 PubNc I4 Other n DNts Depth of Grout Sate -2 Type of Grout iy!s.T G twt,r I I kf4mion _Approx. Depth I I Eastern Surface Seal I nstaNed by FIUJh Grw✓ W411 Gav'or Rspsir Werk Dae U Type of Pump H.P. State Work Dons WON Oesnuction O Won OiiTww :NPSeLlicfy Material A Depth 0800 20zr Ftllw Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is oval"within 200 feet.) Insoft ion wd serve: Residence_ CommereW— Other Numbs of WaV units: Nuatbu of bedrooms ChratRsr of aoN to a depth of 3 fret: Water t"depth SEPTIC TANK, O Type/Mfg Capacity No. Compartments PKd. TREATMN INT PLT.O Method of Dispossi DiRance to nesrast: Wag Foundation Property Lina LEACHWO LINE O No. A Lir%"of Ikea Toth*40/site FILTER SED O Distance to nearest: WON Foundation Property Lire SEEPAGE MTS I I Depth sire Number SUMPS LI Distance to nsanat•. Wag Foundation Property Lire DISPOSAL PONDS O I in sby osrtity Ow I have prepared this appkadon and that the work wM be dare in accordance with San Joaquin county ordinances, stab bus, and ngn and apdaitons of the San Joaquin t:acnn�r Hanna eww or fi eased spitt's*;naam cartiiiss the foNowing: "1 certify that in the mfamernco of the work for which this permit is hared.1 shah not aapfoy arhr perseR In sudt ffdMW as to becom stltfjM to wakme s compert.sOM 10M of CaWornis."ContrseWs Fb►mp or arb•eonal *q Nis rtoft, a oarb'Asa Vie fotawkng "1 caWy that in the pettonn nce of the work for which this owmit is issued,I shaN srnfAoy persons subject to workman's compWAW don bus d CaUOmtis." The appI must CAN for d ratwW Inspections. Comple"drawing an reverse side. Signed x XMPZ,..ftl f 2"A:!% Tine: Sta>:!�' Gea r Date: 7-23•�3 FOR 09PARTMENT USE ONLY Appkdon Accepted by ` Dab / ( -� Area q Plt or Grout IrtpOetbn by /�' ' �-� ate 1 9 Flees Inspection by AddMonel Comments: Applicant - Iteturn all copies to: Ban Joaquin County Public Health Services Haviroatental Health Permit/services "S N San Joaquin, P O 96x 2009, Stka, CA 95201 1� AMOUNT DUE AMOUNT REMITTED CA pN RECEIVED Illy DATE ` PERMIT NO. . IN 1304 INW.t/a at '-/t �oQ / 3 a"04-301