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,AP Pl,ICAT ION ;iAil ,;UAQUIN COUNTY PUBLIC FI•G.11. I „ F.N>'fI{Uv�dF^!T'AL 11Y 1,111 JIB; 1 -145 N ;;,1N JOAQUIN, IMONE (209 41� I' 0 BOX 2099, :iTOCKT ON, CA r )EILdlT FXI'II{E:i ' YEAR r. �� r••,�I.,p 11 p13Ce L'or. to hereby mde to ::nr. .. ... - :Cr .aft .r¢rt nr.., _ :e ill v]r Y. herein: described. Th'8 appllca Ludo :a muds Sn Ca=y1 an:e _tr'-$nn'J U.i3Lln i•rRn•.y+,.r..nanre-F- y=y n.d :Pa2 —d -I.eFRu.ea and Kegu7,_attons cf Sea .. Joaquin Ccurlty Public Healtl: Servllce.. / :ebAddress Owner s Name.[rrJ61LL�`\� �—t-S-:tel-Cl:�•- ::t:;1rr:5: /Jt�r'�G_._�rc1l�I��I� iLJLI`_-•f-_«t--..L-._'!r.-cCK-u--Phone �L�I z�,(' o t c � ISSILtI f �^ ^" s ti3"•Z ;lCN:.�_1.1c jf,___,c.-7!v? No,�JC=�I Pao e TYPE OF WN-LIPUNIP 'll NEW WELL '::E.. REr'LACE!:l'•.T ESTR.ICTrON i.. Out of Service Well •� PUR!P INSTALLATION :- SYSTF:' REP ilii OTHER %onitor:ng Well L. I - DISTANCE TO NEAREST: SEPTIC TANK �] _ SE'::ER 1tiE$ __—____.__.—.- - 'i FLO ._ PROP.LINE i\ - FOUNDATION _ •�,AGPICULT'Jr-E WELT __- fE[.L.____ PITS:SUMPS INTENDED USE - TYPE OF WELL PROBtE•M;,PFA COr4S'RUCT!0K SPE..-riA'.rO'wS i"Industnaf C)Open Bo•tnm ,' l�A..ntuca _ D.a of Well r.catiat.or ,'� Dia. of Well Casmg Yr - 4 6omesht%Pnvale Gravel Pack Tracro Tyar et Las n3 /}�,_ SpecArcatrons G`�' Vi PupGe .. er i Ui;l:a Grpth of Grrn,! Seat —,._./-�, _1 Type of grout_&.4,1rkl7EJ I I Irr1;)alwn .7 Aoj-ar,. Death 1 1 E41111-1 S„r!ece Seal Ins!a-lntl by ![^.41 Repm,Woik Dona u Type of Primp H P -...�...�____.__.... Siva t':ork Dore .Wen Destructor ❑ Wen Oiamelar esittig fteterial t 1?rpth Depth � Fl.l ter t4eterial L TYPE OF SEPTIC WORK. NENY SNSTALLA11O'- I,EPAIR'ADOITIQN DESTAUCTION r r INo septic system pefmwed it public sewer is available wsthrn 700 feet.f f, _ IM:allalron will serve' Fesidence— Commerc-as C-:l,er —....—�_ - Numbei of living units:— Numaer of bedrooms Chtfactef o![oil to a depth of 3 feet' -- Wase'table depth - -- SEPTIC TANK E� Type/Mfg Cap-ttdy„ _ No. Compartments PKG.TREATMENT PLT.n Method of Disposal Distance to nearest: Lyell Foc.ndn Yon-_ _ P'oneny Line LEACHING LINE C1 No.L length of lines .- _—__— Total iengmis-le FILTER BED CI Distance to nea,a.t: Wet. —__ Foundalwn Property Line SEEPAGE PITS 1 I Depth —_ S:tie --_._ _____. Number SUMPS 1.1 Distance to'nearest: Well_�_._ Foundation — Property Line - DISPOSAL PONDS 0 I hs:-'"_y C:rity that I have prepared this application and mat the wort: will ire Conu in accordance with San Joaquin covniy ordinances,state laws.and rules and rogulatir.ns of the San Joaawn County Home Ownef of licensed agent's s,gnetufe cert,ties the 101!owmg:"I coMlY:hat In she alto!rnan6a of the wo-k for wflich t)eis permit is isausd,i shell sof employ any person in such manner as to heCome subject Iq woekmo^%cempensabon laws of Catdo+nre_'Contractor's hiring Of Sub-Conlraefing signature tlrtifies the following:"I certify inn in the porformarce of the work for which this permit is Issued,I shall employ paranns subfact 10 workmfin's compansa. tion laws of Calif fnia.'" The appri st calf fo�rr rant rrequeed pections. Can,plyta drawn o a�rsa sIC SignedML - / F'''OR"''D"''EIT/.ENT USE ONLY Appl;caugrt ACCe01e4 by y --- --�-- ._ Date Pa or Grout nspeclion by —. 4. j -�te 1`'` Finer lsapetln)n by Dale Addtttonsl Comman+s: .t .� J_>- f L'i.-fai- L ✓: - Apl`I lrnnt - Rrturn all rn, -t, [e: San .Jnay¢.n Cnunty Pvhl lc ri:elt!I Se•r�:r •� - 6nvironmrnta! F'^rsrl t/,S'crc Ice!, Ads „ S n;vl;rin. I! it 11n!r '019, Stkr„ CA 9521't - - FEE AMOUNT DUI: AMOUNT REM07LO CAS I +ECEIVED 9Y I DATE PERM'T No INFO I �c� �r� G,`;3 73 �( 3/2 . [a is 1.LSEv i..tl�' - r