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APPLICATION FOR PERK I T �� #'�� SAN JOAQUIN COUNTY PUBLIC HEALTH SS[tVI•C�S�?C-� EN WIROMIENTAL 11RAI,TH 1);-VI5 # /, 445 N 5AN �4 JOAQUIN, PHONE (203) 64Zn-- �L P 0 BOX 2009, STOCKMN, CA J6 1 AP (complete i. • 11 atem � Appllcatioa is hereby mde•ta Sao Joaquin County for a perntt for tndJe7 In�� .1_'the vork herein described, This application i■ rude Sa cau+llance vlth San Joaquin County Ordlnan- ,49 and 1862 and the Rules and AeguliLtiote of San Joaquin County Public Ifealth service, / Joh Address ✓ ��y��. y// f rGL/ +{J Owner's Nn:. �_'' .: Phone Contracts - dress n G: !" TYPE OF WELL/PUf P: r.eW VJELL 0 //�nsa No, Doone WELL REPLACV-iENT C3 DESTRUCTION Cl Out rr &errite Ye11 Ll ¢ �'' '.•:� PU.:p 'STALL,' !"IN G SYSTEM F.F,PAIR Cl OTHER ❑ Monitoritla Vell ❑ DISTANCE TO NEAREST: SS?+,C TANK SEt"rER LINES DISPOSAL FLO. PROP. LINE p ''-r i. FOUNDATION AGA: TUR' cLL OTHER WELL PITS/SUA1P5 r ;-N'% ;•at„` i+ice .,,� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •�, ❑Industrial U Open Bottom 0 Manteca Dia. of Wall Excs fron Dip,of Won Casing r� %1 Oornestic/Private 0 Gravel Pac► ❑Tracy Type of Casing_ Prrbl,E f.1 D1her fl DSpecificatorl: _..1 ay a i ;I elta Depth of Grout Seal TyPe a `�1 l Grout \ s. r „r•�: e� ,'f I I litigation_ _Approx.Depth t I Eastern Surface Soul Instilled by R U Type of Pu .r� rF 1rR Fes_. 'a WaE DOrls mp H.P. ON Destructionm ❑ Well Diameter Sea.11ne Naberial i Depth Stne Woe Dona \' r , •t Ospth Filler Material A Depth �, z$ •z^ tij TYPE QF SEPTIC.WOAK; NEW INSTALLATION I REPAIRIADDITION I I DESTRuCTlON I INo seplrc sysrarr.Permitted J a e Koff l S.: Pe public sewer is available within 20)feet.l - .T �`y+=+•:arS ,&t r� _ ,• * Irlsttllletion will serve: Resioen.:a L Cortvrarciar`. :her ¢.:' 1 4 t Number of living unite: Number of bedrooms� ^ ,TAN::, y'{1 Character W kA to a depth of 3 feet: J Water table depth SEPTIC TANK. n Type/M1g PKG.TREATMENT PLT.[! ' Capacity No. CI>rr+psrtments — 4' Method of pia.3ots1 ,l� Distance to Merest: Wali ourMation• Property Line---y/-J1y�•��Lan �xY ""LEACHING LINE � No. Long th of rings Total length/site ftp 7 5 { � ' FILTER SED ❑ Distance to neaten: Well Lina l ti. r1-qa5 rwz1i_ FourMation Property' :SEEPAGE PITS 11 Depth eve _ Number s -iJ n SUMPS L! Distance to nearest: Witt (] Foundation Property Line w' DISPOSAL PONDS ❑ 1 hoe Comm that 1 have . �Y W Prepared thk application and that the work will be dorsa in accornance with San Jo.:quinances.silts taws,and �r 3 t Y'- .rules and fptyaliorta W the San Joaquin County n county ordi HWM OVAW Of licensed agent's signature clniriel the InA0wiA9:"I cartify thar in the performance of the work f()t which this permit is issued,1 eflatl not ` u'! i r tis employ af+'f person in such milinnOr as to became subject Io workman's comoensalion Lewy of California,-Cantractofs hiring or Waponttact' Corollas the 000*Wog;"I C04NY that in T!M aerbfmarlce of eta work for which this permit is issued,i aMII em la °W signature =�` Nr�r P•,?car -. _>.tfon Iwa of Caldc"11e." - OMPICY Persons subject to vroriman'■eompen", x A 1?'� The r"Ilf—r t or ell K�, s rpuk Icons, COrtlptele drewing on revefse antis. SIg.lW St_ Title: oats: T r Y, FOR DEPARTMENT USE ONLY ' nt h ' Af>tltWn Aecepted by�^ -G �}-i�i� a s a low I flracDon by Arcate _ f , f Da a Final InaDectian by /•��"��`-'pate_.LC�'�,� AddlifonN CO M.Ants: / f .;,• ; ,applSeant - Return all copies to: flan Joaquin County public liea1t6 Services q,_ s Eaviroft ental Health Parmlt/Serrlcea t� �s r t-�\ aa5 H Sao Joaquin, F O trot 20ob, StkCA p' n, 85201 ti `. FRE 3 LMDIlM7 D!]E. AirtotlNT RkhtITTf6 CA H RECEIVED RY DATE PERMIT, a! its13-24 1119V. * Err 1e.as .t� , f. 93 r ase 1' F i r�''•"`'.'R' "^! '} x "3hv•....,;•an- y.,d=.*.. X— .. .— 5 421 �w y1-y 4