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SL.h JOt+Q%iF C'ou^Zt':'-v PL't'..:.I C �L'. E SEEVI CES <br />Eh'VI EC.'r'YEi► �h.a.. =AL - <br />LE D I T` i 5 I ❑2r <br />445 h SAN JOAQulh, PROKE (209)465-3420 <br />P 0 BOX 2009, ST0=T0N, CA 95201 <br />PEPX17 =!XFXS 1 TEAF FROM DATE II SS= <br />(Complete in Triplicate) <br />A,mlicatice is berebr made to Sam Joe.qulz County for a yerait to construct and/or iesull SAe work herein described. :'his <br />spy_icatioe is aade iz ccsiplianee with bas Joaquin County Ord:namee ho. 54P &M IW and the Rules and ReFtlatioae Of Sam <br />Josquia County Public liealtt berrieea. <br />.lob Address C 7�p �r✓'a V Crty S%GCKTD �✓ Lot Size/Acreage <br />pwrwr s Nem• <br />Address Phone <br />G <br />1,461 lrALCSS <br />Zb 96 Pnont9iE3rt7�OD <br />Ganuaclo^f <br />TK N Address WFST �'-R�FM �'Q1 License No <br />TYPE OF WELL/PUMP <br />NEW WELL i7 WELL REPLACEMENT n DESTRUCTION 0 Out of berries well D <br />PUMP INSTALLATION D SYSTEM REPAIR D OTHER D monitoring Vc.0�r <br />/'� <br />D'STANCE TO NEAREST <br />SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />�) Inoustrial <br />❑ Open Bottom 2] Manteca Dla of Well Ex"vatlon ^!G Du of Well Casrnp <br />n Domestic/Private <br />.13r-Gravet Pack ❑ Tracy Tyne of Caarng lyc Specd" tions ��F <br />I% Public <br />n Other 74Delts Depth of Groul Seal N � % � Type of Groul&FA/ rE/'7t�+/�' <br />i <br />I I Ifrepation <br />Approk Depth l I Eastern Su ecu Seel Installed by�CirLS r0✓ Sl�Rm/cFS <br />Repair Work DonD <br />Tyof Pump ►�,Ia H P State Work Dons N <br />Type of <br />Wel Destruction ❑ <br />Well Dwrletar I •JCH Seal sag Material & Depth 6 !/ �3/ ) i ' 9� ro.✓i7� SI' �0 33 / <br />Depth ^' 59 F -Ft'>' riper material i Depth �3 s'a,✓�, "' - -SS FF�y <br />YPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IND septic SYsterri germ111e0 Al pubitc sever n <br />ava,taws vwthin 200 lost ) <br />IriataltateDn midi aarvt Ros+denos _ Corrime tial Dow <br />�Aiumbwr or feven9 unni Number of bedrooms <br />Chmackot of sort to a depth of 3 trot <br />SEPTIC TANK C Type/Mfg Capacny <br />PKG TREATMENT PLT C <br />Water table depth _ <br />No Compartrrlenu <br />Method of Disposal <br />Drstanu to naaraat WaII Foundation PIDDeny Line <br />LEACHING LINE 0 No a Length of larges Total Ienpth/adze <br />FILTER BED ❑ Dazwice to nearest Wet' Founc;stmm Property Line <br />SEEPAGE PITS I I Depth Sire Number <br />SUMPS LI Dowries tD nearuc Wet' Foundation Property Lair <br />DISPOSAL PONDS ❑ <br />I rwetry Candy that I hams preparrC this application and tnai Iree work wiu be oone in &M Cance vAln Sen Joaquin county ordinoners state lays and <br />_ res and +equlatione of the San Jcapuen CmmV -_ - -- -- - - <br />home P-ner or kiar aa4 again s wpnsturs omifess the folio.vinp -1 eertrty that in the prAorrnance of the wart for vAuch the permit a naasad. I sh" nos <br />0"0" 6"Y Poll NX in such nw~ an to lb - Cc is wboet to workman a Compensatwn laws of C Morrw « Contracsoes hrnnp or sub-cart:raeurig signature — <br />ta WOft VW 1D&CV4%VV "1 Cmwtlty that in Ins psnarnw+ea of The work for %which rho permh Is issued I shall •mpkay persona sub)oCl to workman s Compansa <br />tion "we of CaaAonua " <br />Thf &PP6Can1 must cat to all ►•gs+.ad rupo tsons CoTW:)w%e orewenq oda <br />n rtversa sa <br />�+ --,,7/-,,,/ �- Trite A S Svc rrc ,-F G P=eL.c.s i 5 " Date ) Z�23-f4 <br />FOR DEPARTMENT USE ONLY I <br />J <br />Applacrtio'i ACCapteC by Date Area <br />Pr o+ Grovt Inepocum by Date Fina! Irupet•tion b1 <br />Date <br />.Abdauonal CDrftwwnu l <br />Applieaot - Return illi eopl ee to Sas Joapt.ii: CouotT Public i}es_tL Scr•1Cee 761) <br />bcriroamertal Healtt yertit/Se-*ices <br />445 R Sat JDaquiz, ]S Bo: 200P. Sikz, CA P52D1 <br />FEENFD Af•A.7l1NT Dug Ak60U� Rlatt-TED i M RECEIVED AY PATE 1 A�RMIT I� " <br />�J�T Z b 1199513-N Iiiry i w •t I [� 54.1 <br />.� fQ� t 5"' <br />