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�ttrLt" SAN JOAQUIN COUNTY PUBLIC REA--.1 SERVICES
<br /> ENVIRONMENTAL REALTH DIVISION
<br /> 'Pfr 445 N SAN JOAQUIN, PHONE (209)468-3420
<br /> P O BOR 2009, STOCKTON, CA 95201
<br /> ' PERMIT EYDIRE9 T YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Applicetion 1. hereto, reale,to Sao Jeagufn County for a yermlt to construct and/or ln"ll the work Lereln described. This
<br /> aMileation is aside in eoopllance with San Joaquin County Ordldance No. 549 and 1962 and the Rules osis ReKULn
<br /> tfens of Sa
<br /> Jpaqule County Public Health Servlets. Q� ,.,.,./ /�
<br /> ,:� lA/, ✓��Qt/ Ci,Yfl(�'�1_ Lot SSse/AcreeSe
<br /> Job Addn A'� •I /� f�
<br /> Tn11Ms �f 9FD Address
<br /> Phone
<br /> OwMr's Nems �j//i' �f /��ya.� �P�jh
<br /> - Com'.c10r_ .-a.LLea Address r1 �1�LAiA7f/J2�License 143.67..7�G Phone ;
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<br /> TYPE OF WELL.'PUMP: NEW WELL ❑ WFLL REPLACEMENT fl DESTRUCTION 0 Ouc of Aarylce Nell ❑
<br /> Iknl CorinS ll Na .+
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G :1
<br /> q� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._— PROP. LINE _— f
<br /> FOUNDATION _—_ AGRICULTURE WELL __ OTHER WELL-- PITS/SUMPS
<br /> y� i'
<br /> l' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s,1
<br /> ❑IMunrNl LIOpen 50110d, 0 Manteca of.,of Well E.awtion CIA,of We"CMq
<br /> ❑Dortenk/Private 0 Grsval Pack 0 Tracy Tvoe of Cuing------ Sp Ty,pe S,de of Greu
<br /> tloM
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<br /> I Public 1-1 of", fl Delta Depth of Grout Seal \\ ;
<br /> I ft".bol _Appeo..Depth 1 1 Eutern Sudaa Ssal IM41Nd W
<br /> Repair Work Dons U Type Of Pump H.P. Sun Won DOM
<br /> B..1leff Racerial a Depth
<br /> WallDaetruetlon ❑ Weal Disms,ln Pillar Nsurfal A Depth
<br /> Depth
<br /> TYPE OF SEPTIC WORK: HEW INSTALLATION 1 1 REPAIR/ADDITIO. OESTRUCTIOh Ileo upI¢syne2 pe+mt4d,t pubAc a1wal b
<br /> .G avai40N wilnin LOO if i
<br /> ii lmtaMfNn"an": Residence ComMrcLel Of",
<br /> e Number of"un4:--t- Number of bedm
<br /> roos ..3 -
<br /> $$ CNnc4r Of WN Ip a depth of J fast: Warty table Neth
<br /> SEPTIC TANK O Type/Mfg j?4' GpscitY No.C,NnpMtrMn4
<br /> {!' PKG.TREATMENT PLT.0 //11t�r�//,�''.// t �F
<br /> q Dle4nca to-21"t: Well6- )#T Fdwpov ion yoI Property Line
<br /> 5! _ � 7—
<br /> r�
<br /> $CCYY LEACHING LINE O No.A Length of lines
<br /> FouNation A= Procerty es r Tlen o,is, Lire
<br /> ¢e
<br /> FILTER BED Distance to ~��
<br /> 0 hospital; aT�'
<br /> s SUa NumCer a IN //pouf 7
<br /> ` . SEEPAGE PITS f�IDepth r 9ro0ertY Lida
<br /> Ij SUMPS Cf/D+teMe to l t: Wall t ouM
<br /> Fafon._ao.e_.� f -
<br /> (,( DISPOSAL PONDS ❑
<br /> t 1 latestfwtNY that 1 hews W"red this"kation and that the,wok will M dobe M accordance with Ssn Jopuln county o+tliMrKM.e44lewa and ,
<br /> rule arA"'Itstorte of tN San Joapuln Count/ ,Y
<br /> Hone pawner or kensed ps,nt'e eipMlun anifias IM following:-I candy the,In the perl ,,hone of tswop for wich this perms le assured.I Stas not
<br /> h
<br /> employ any p~In such mMMr as,W DepMte subject w wArkmen't cOmpenaa�n Owe of Californ I Contractors n,0rg Sub-COniractMq YpMhMe
<br /> centrals the Ipbwinp:"I bendy that in IM pedortnanpa of IN Wolk for wTlch this not is Issued, D Y persons lublact m wConniption"ortfas a Conniption"
<br /> tis+Lewes of California." ;
<br /> The spplicant noun caa for Yytqu�kupso ions.Condemn,Mawiltp on ravens,aide. y✓��.
<br /> Sighted k
<br /> �/1 _ ?
<br /> Title:: Date
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<br /> C 17118E ONLY
<br /> Date A
<br /> . Appacetbn Accepted Dyy
<br /> PN or Grout loapectlol W
<br /> Data Final Inspection DV Oa4Q
<br /> Additional Can rears
<br /> T Applicant - Return all copies to: ::Of
<br /> ao Joagy 1p County Vuhllc BMIth 9xrvltea ±4"
<br /> Bayirowauntal Nas1th Pereit/eerwtcea i. e
<br /> e i NA N Ban Joapuln, P 0 Boa 0006, Stith, CA 95201
<br /> t1 "
<br /> A NT DUE AMOUNT REMITTED
<br /> IBM LINED aY 0 TE FlRktll'N0.
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<br /> . n� yl 'rs ,.:n..�..:w'n.a hOuvw:YlelAmilMiPMr,t,wA'ML
<br /> i �..f:i.Sli.:,'nLe'.rore9+�"wYM1U95'�..e+w,sv; .,..s ..,o w>.•y.V,.141'dl...r.l+l.l:vesi:A+Ato=:s•wr.. F. b,�.
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