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Tuesday October 4, 1994 17:10 -- Page b 10-04-1994 05:07PM FR TO 19169208463 P.06 JA � A1'1'L1l:H"l-i VPt � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k I- ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-5420 P 0 BOX 2009, STOCETON, CA 95201 -QERMIT EXPIRES .I YEAR F PATE ISSUED (Complete in Triplicate) FERMIlISLI?VICES Application is Hereby trade,to Sen Joaquin County for a permit to construct and/or install the work herein described. 1'his ayyll.cation to made in Ccrripliance vlth Stn Joaquin County Ordinance No. 5k9 raid 1962 and the Itulee aild Regulations or San Joaquin County Public Health Services. I T Job Address Wase wa��r Tread +�n.�'ivtT P I a^n� City 1 Lot Size/Acreage f1 T Owns:a Name I�o,rr e.I I �. Secy}�, C i! o�Trn v Address `�o �� .Jrl Vc_ �YG C / Phone Layne Env . Drilli PO Wof)Xod 1326 510011 Pharle( 416 ) 662-2 25 CantractContractor_Lay _ � �dre9s� ld 0 o 0 c� � d n d , CA 9 5 7 7 6 License No. TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Serylce well L-I PUMP INSTALLATION O SYSTEM :r£PAI.I Q OTHER O woitoring Well )E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD- PROP- LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr n Industrial 0 Open Bonom 0 Manteca Die- of Well Excavation Dia. of Wall Casing Ll orrlestic/Private )K Gravel Pack X Tracy Type of Ca_orrg _ �V� Speciew- Sion -- tabllc n 01her 1"1 Delta Depth of Grout Seal to, Type of Grpot5%&-LAI OkAi k - I I krigaiion —Aptxou. Depth I I Ea5terrl Sutlace Seal Installed by LM N E E N v.I R I Ll,i Ntr Ce Repair Work Done 0 Type of Pump H.P. State Work Doyle_ W&N Destruction O Wee pixneter Sealing Material Z Depth qty, Tiller Material i Depth Ty" OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public Sewer is available within 200 feet.) Installation will verve: Residence_ CorwnercW— Odler Number of Going units: Number of bedrooms / _ K Chwact'ar of troll to a depth of 3 feet: t Waw tabb depth SEPTIC TANK 0 Type/Mfg . No. C wnportmsrtp PKG. TREATMENT PLT.0 Method of Disposal Diwance to nearest: Wei Foundation Property Lire LEACHING UNE ❑ No. b Length of rwms Turd length/sue FILTER BED 0 Distance to rmwest: Well Fwn0atiotl Property Lkw SEEPAGE PITS I I Depth Sire Numbw SUMPS Ll Oiatartce to nitarest: Wad ------___--- Foundation Property Lira DISPOSAL PONDS 0 ` I hereby certify that I hews prepared this app"tion end that the work will be dont in accordance with Sin Joaquin county ordinances, stats laws, and rules rand regulations of the San Joaquin Cooats /tans owner or licensed apant's signature arrtifita the foiloeving: "t certify that In the perio"niiince of the work for which Veit permit is issued. I shall not employ any Hereon in such AWMrw as to became subject to woMrnan't compenso6on taws of California-" Contactor'%hiring of sub-contrecting signature ewt�iruat tla following:"I certify that in the pedomtancs of the work for which this pwrrit is issued,I sh6N smptay perapne subject to workmen's compensa- tion laws of Cauf0mia." The opobont myat call tw ON ragtai"i t Cornpleto drawing on reverse side. Sigr+ed X / _,___._ Title: Yip,cc nT4i►fa�P/ - c N�m H 1 Date- FOR FOR DEPARTMENT USE ONLY Application Accepted by Date _ Ansa Pit a Giroux Inspection by Datta F-wW Inspection by Data Additional Comments. Applicant - Return all copies to: San Joaquin County Public Netlth Servlceu Z-9� Gevironatental Health Peratit/Servicos 446 N San Joaquin, P 0 uox 2009, Stkn. CA 95201 �N AMOUNT DUE AMOUNT nroA TTED CASE ECEriFO ev DATE ►EftMIY rrO. T - �9.� 10 (D /9 9� Page 13A 6N 17-21 Ilan/.t i n u 1� EN 147A