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Tuesday October 4 , 1994 17 : 10 - - Page 6 10-04-1994 05 : 07PM FR - TO 19169200463 P _ 06 II AI � N�A SAN JOAQUIN COUNTY PUBLIC HBAI,TH SERVICES qqt ENVIRONMENTAL HEALTH DIVISION it 445 N SAN JOAQUIN , PHONE ( 209 ) 468-3420 P O BOX 2009 , STOCKTON , CA 95203. PERMIT 8%PIRES 1 YEAR fA_QK DATE ISSUED FNS✓IIs CJMF ll !VL IEALIFi ( Complete in Triplicate ) F[F:MITISLIwIGES Applicatlon 1s liereey aade , to Sao Joaquin County for m par-nit to corm r t and/or Install the vork herein deseribeo . Thio application in sede In Crmpiiaice Lith San Joaquin County Ordinance No. 549 and 1062 and tba Rules mod Regulations of San Joaquin County' tPublic ,f� Healt lh Servlcee . . . . Job Address y`/�"S'I C'- WC( FQ.Y Trp o4yA �, � rho— A+ City Tri L `/ Lot Size/Acreage T CII Oj - Owners Nadu lo, I tTrn ry Address -`n 00 N' 11 V�� I rG Phone a ne PO B X 1326 ContractorL . Y . Env . DrillsrABdress WOo � land�, CA 957. 76Licemt: Nn. 510011 phons ( _916 ) 6F2 -_2 25 TYPE OF- WELL/PUMP: NEW WELL 0 WELL REPLACEMENT L7 DESTRUCTION 0 Out of Service Well U PUMP INSTALLATION 0 SYSTEM F £PAIR ❑ OTHER 0 Monitoring Vell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u 0 Industrial 0 Open Bottom ❑ Manteca Die. o/ Wea Escavarion Die. of Was Casing El ornsstic/Private )K Greve, Pack >4 Tracy Typs of Ca:ng _ pyd r ^� $peiticatkars {�� I - til3k n DOW n Datta Depth of Grout Seal 110A Type Of Grpur$% UCk1041 k - I I hrigation .,_ Approa. Depth 11 Easteum Swfutf Seal Inslahed by YN6 ENV. �ARILLI N(r �e N^ e..r Repair Work Dona 0 Type of Pomp H .P, Stitt Work Done _ Weer Destruction U Wed Diarnmer Baal`rag Material 8 Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR /ADDITION I I DESTRUCTION I 1 [No septic "am permitted if public Sower is a raitom within 200 leat.l hutadauon will serve: Residence _ Cornmorcial Other r Nuolbor of living units: '— Number of bedrooms t Character of sad to a doom of 3 toot: _ ' I Waror table depth SEPTIC TANK , 4 Type/Mfg 'i;pacrty No. ComfuIrtments PKG. TREATMENT PLT. 0 - NMthod o1 Disposal DGTinoo t0 Rtarest WeN Foundation PM"rtv Lint LEACHING LINE Ll NO. a Length of Fines Terd Imrgth/sus FILTER BED 0 Distance to nesmst: Wed Foundation Property Lia SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to manner: Wed - _ _ -- - -. Foundation Proparry Line y DISPOSAL PONDS 13 1 hereby conify that I heva preputd this application and trWt the work will be done in ac :wdan_ce with San Joaquin county endinanCes, nope Lowe, tinct d miss And regt"braps of the San Joaquin County Home owner or licensed agaWs signature cerdfiea the lokoumrg: "t comfy that In the perfornynce of the work for which this permit is issued, 1 shad not employ arw person in such dW War as to become subject to workman's cvaynns"m laws of California." COtwactors hiring or sub-contracting signature k cerliGse the folowarg: "I GMUTY 11141 in IM performance of the work for which this permit is iesuad, 1 ahoN errpby penia subject to workman's Campania- tic" laws of CaNfonda TM Applient /met ceN la ON "M" kI q 'ere. Conyla40 drawing on reverse Sigrid / Tido: Yin . �P/' — C YI2rt1 Yl l Dots: - MR DEPARTMENT USE ONLY Appkcatidn AcreptW by Dale _ Ana N at GrauS hepactlart by Date Final Inspection by Date Additional Comnenni Applicant - "turn all copies to : Set Joaquin County Public Health Servlcea 2qlv goviroonental Health Permlt/ Ser9leoa 995 N Sao Josgttln , P O Bos 2009 , Rtka , CA 95801 INW AMOVNT EE AMOIrNT NEAt1TTED C KtSN ECEmv4D @Y DAT, PERMIT' ND. Page 13A . SN Iiia recv. r , at. 'S 1 8q . �a ' g+ I coh5 4 FN laal