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fi APPLICATION SA.ti JOAQj+IN COUNTY PUBLIC HEALTH SERVICE5 EN VIRONMEN7AL HEALTH DIVISION Q , —=5 N SAN JOAQUIN, PHONE(209)469-3420 f U L 0 8 1994 J" P O BOX 388, STOCKTON,CA 9 �2 01-0388 P;gMIT =IRES I YEAR FROM- DATE ISSUEjNVJR0NMENTAL HEALTH �J (Complete in liplicaze) PERMIT/SERVICES i is compliant:With San Application is hereby made to San loaquin G_r.:1 tar a?etTnit:o construe and/or install the work herein described.This application:s made ll county Development Title Section l-C.3 anal Section 9-1115.3 and the Rules and Reguf I tions o�f/San r,lo_a}gain County Pubiic H-1- Services. 2431 M P,0-t P o St, R-D C-tv S��a t� Lot Sizc/Acreage Job Address -m 5, �� Phone 141 _8 56 Qwnar's Name ACtlress T25 E . M Y rP_.r —€i Sr: P"ane Cantlactar SPEG�-L�N� ^-- a Zb License Na.rJ 1 226 1 TYPE OF WELL/PUMP: NefV 'NE'.L ❑ WELL REPLACEMENT';;, DESTRUCTION Out a: service Well `-i PUMP INSTALLATION M SYSTEM REPAIR;" OTHER i4onitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD.� PROP. RINE Z FOUNDATION �� AGRICULTURE WELL -h242 OTHER WELL PITSISUMPS JJA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f MI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. at Well Casing Ll:.. pomastie/Private ❑ Gravel Pack Tracy Type of Casing_ _,Pvc- Specrtications I'1 Publico Ott, Deux Depth of Grout Seal to 3 Type of Grout PLO L -!l1 �0 l I i Irrlgaadn pprdx. spin Eastern Surface Saul Installed by Repair Work Done U Type of Puma H.P. � State Worst Dona_ L Sealing Material i Depth } Well Destruction ❑ Well Diameter h I Depth _ Filler Material i Dept `t TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAI141ADDITION l I DESTRUCTION I I INC septic system permitted it public sewer is available within 200 toot.) installation will serve: Residence— Commercial — 1001e1 Number of living units: Number of bedrooms o Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity l No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: well Foundation Property Line EI. LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Weil Foundation Ej Property Line ii SEEPAGE PITS It Depth Sire 1 Number SUMPS Ll Distance to malarial: Well Foundation " Pfoperry Line n DISPOSAL PONDS ❑ ? I hereby certify that I have prepared this application and that the work will be done in accbrdance with San Joaquin county ordinances, state Laws, and rules and regulations of the San Joaquin Coull I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shalt not employ any parson in such manner as to become subpct to workman's compensation Iawslof California.- Contractor's hiring at suo-contracting signature certifies the following: -I certify that in the performance of the work tar which this permit is isaued. I shall employ persons subject to warkman's compttill tion laws of California." 11' The app u call IW all fjoeivirad t s tions. Complete drawing on reverses side. 11 �1 Q Signed Title: Date: , L Il FOR DEPARTMENT USE ONLY /y Application Accepted by r✓ _�� Date 8,l Area L—C) Pp_00 j 'i Pit or Grout inspection by Data Final Inspect{tion by Elate Additional Camments: ii Applicant - Return all copies cv; San Joaquin County Public Health Services Environmental Health Permit/Services I a-t5 N,San loaquin,P.Q.Box 388,Stockton.CA 95201-0388 !l a ' FEE aMOUNT OUE AMOUNT RE?1lTTEO GK RECEIVED By GATE PERMIT NO. c"+ INFO CASA fH 13.24 fREV,ti rt5 i �U'7 I r � /