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MAR 2 9 1994 JP-N JOAQUIN COUNTY PUBLIC HEAI ENVIRONMENTAL HEALTH D I V.L.,I ft JA N SAN JOAQUIN, PHONE (209)46 *1 go EN`PERW I SERVICES TAL HEALTH P O BOX 2009, STOCKTON, CA 95 PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) S Application is hereby made to San Joaquin Count for a application is made in compliance with San Joaquin r a Permit to construct and or Joaquin Count / install the work herein described. VThis County Public Health Services. Y Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Job Address ��7 f u MEMEWAY JUg VC 937ct to City�G 1P� Lot Size/Acreage 13Tjf Acr Owner's Name Wi4L1'.Q � ,d /cTn1 N51f 3" 3 _ Contractor—PAUNBALqp Address 10-334E0.�WODDR/D F Phone Im %ddress "!9 [ n KC 19638 6 3 TYPE OF WELL/PUMP: -------- s L Cense No, NEW WELL ❑ WELL REPLACEMENT ❑ �—Phone 3f! PUMP INSTALLATION ❑ DESTRUCTION ❑ Out of Service well O DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR OTHER CiMonitoring well -- SEWER LINES DISPOSAL FLO. FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL PITS/SUMPS ❑ Industrial CONSTRUCTION SPECIFICATIONS ❑ Open Bottom El Manteca Dia. of Well Excavation Ci Domestic/Private Cl Gravel Pack Dia. of Well Casing f"I Public E� Tracy Type of Casing I1 Other 9- --- Specifications 1i hn(lation I Delta Depth of Grout Seal _ Approx. Depth 11 EasternType of Grout Repair Work Done U Type of Pump �— H P. Surface Seul Installed by Well Destruction ❑ Well Diameter State Work Done_ Sealing Material t Depth TYP Depth Filler Material i Depth E OF SEPTIC WORK. NEW INSTALLATION 7 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system Installation will serve: R M5_ /3�� permitted it public sewer is Residence_ Commercial / available within 2tp feet.) Number of livingunits: Other ___ PF,p0p1,�TiO/�/ �1p Number of bedrooms /, TESTo 4- PAK6 Es Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT, ❑ Capacity._ No. Compartments Distance to nearest. WellMethod of Disposal -----_ Foundation Pro rt Pe y Line LEACHING LINE ❑ No. 8 Length of lines FILTER BED [) Distance to nearest: Total length/size Well Foundation --- Property Line SEEPAGE PITS I I Depth SUMPS --Size LI Distance to nearest: Number DISPOSAL PONDS Well — Foundation ----______ Property Line 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance rules and regulations of the San Joaquin Home owner or regulations 4 County sed agent's signature certifies the followin s, state laws, and employ any person in such manner as to become subject to work kman"s certify that in the laws of California." Contractor's hiring or sub-contra certifies the fotlowin Performance of the work for which this permit is issued, I shall not tion lawn of California. certify that in the performance of the work for which this permit is issued, I shall em to P Y Persons subject to workmants Som nature The applicant ust call for all r iced inspections. Complete drawing on reverse side. Dente Signed Title: �l E/V T FD12 �� P � _ Date- Application Accepted by OR DEPARTMENT USE ONLY Pit or Grout Inspection by U — Date Area Date Final Inspection by Additional Comments: � y, w-, — ��_ "ats�'� li(.ant - Return all copies to: Y San Joaquin County Public Health Services C Environmental Healt /Services FEE Sz �3-�f(i42 93+�� 445 N San Joaquin, h PermitP O Box 2009, Stkn, CA 95201 AMOUNT DUE •/fy� IN 0 AMOAMOUNT REMITTED CK 124(REV.i i n 51 _ RECEIVED BY .� /Z. U L� 12 • 00 DATE PERMIT NO.