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APPLICATION FOR PLPJ&IT SAN JOAQUIN COUNTY PUBLIC HEAL'T'HSRLU S ENVIRONMENTAL UEALTH DI'VI 6-5 P O BOX 2009 , STOCKTON , CA 5�tft . (209) 468- 3420PERMIT EXPIRES I I��// R (Complete in Triplicate Application is hereby made to San Joaquin County for a permit to construct acrd/ r � 1 I.—Ithpri- Thin application Is trade in compliance with San Joaquin County Ordinance No 5L9 and Joaquin County Public Health Services APAJ 14q- 210 -o I Job Address 80 E�M�Iki 5 _ _ City �T�CI<TOAJ Lot btze/Acreage ,t1Z.4, Owner& Nama&2,z61f?��IDt11�F C ��Address P 0 ay6X x'723 �ST Phone 94�- 3 13 l Contractor +�" ►Lddress 231 coy,= l� `�514�_ License No l7ZG/ 7 Phone - - `95-SV TYPE OF WELL/PfJMP NEW WELL ❑ WELL REPLACEMFNT n DESTRUCTION O Out of Service Well Cl PUMP INSTALLATION 0 SYSTEM REPAIR OTHER r� �JMonitoring Well 1L- F�o2j../v DISTANCE TO NEAREST SEPTIC TANK N/ SEWER LINES _ _ DISPOSAL FLO iV//1_- PROP LINE -'T' _ r` FOUNDATION �.T� AGRICULTURE WELLi✓,/eA OTHER WELLPITS/SUMPS LVL,4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' b�'�}rU} rl Industrial O Open Bottom ❑ Manteca Dra of Weti Ex�evalion "� C��r Loi M1'lrC�in� I� (Domestic/Private Cl Gravel Pack ❑ Tracy TNpe of Casing _ XoN� Specifications f M Priblic )4Other p Delta Depth of Grout Seat SuqF,&Cr Type of Grout dC �*F^i G IrrrUaton 4Q: Approx Depth ❑ Eastern Surface Sedl Installed by _CaN�QacTdrx {- Repatt Work Done U Type of Pump H P State Work Dona Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Materia] i Depth TYPE OF SEPTIC WORK NEW INSTALLATION O REPAIR/ADDITION M DESTRUCTION CI INo septic system permtted rl public sewer is available within 200 feet 1 Installation will serve Residence _ Commercial _ Cilihar ..4 _ Numbs? of Irving unto Number of bedrooms ft1q-F T C Character of sod to a depth of 3 feet -J r ---- �_„____Water table depth � SEPTIC TANK ❑ Type/Mfg Capacity_ No Compartments PKG TREATMENT PLT Cl Method of Disposal Distance to nearest Well Foundation — Property Line " ENT LEACHING LINE L'] No b Length of Imes T__,_, Total length/size — RIMEIVED FILTER BED (-I Distance to nearest Well Foundation _ _ Progeny Line MAR 1 1994 SAN jOAQUIN "~'' SEEPAGE PITS ' r l l Depth Sue _ Number ni ioi it urns Tt..t SrRdICE5 U SUMPS Ll Distance to nearest Well Foundanon _ Proport,, lEWIRf)hIM1:NTAI HEALTH DIVISION! DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be don" in 11CL01dance with San Joaquin county ordinances state laws rules and regulations of the San Joaquin County Home owner or licensed agent a signature certifies the following I candy that on the txtriormdnce of the work for which this permit is issued I shall not employ any person in such manner as to become subject to workman s compensation laws of f alrfornra Contractors hating or sub contracirng signature certdiss the fallowing I certify that in the performance of the wort for which this permit is issued t shall employ persons subject to workman a compensa tion laws of California " The applica�nt�fmu call 19r all required inspections Complete drawing on reverse sids Signed Titled Date 3 FOR DEPARTMENT USE. ONLY Application Accepted by a2Date � r • Area Pit or Grout Inapacttan by Date Final Inspection/�by i Date 4Fditionsl Comments �• ) �J r -t-LAA +� OF t Q M L 5 1 5 �� G10--i 1•_1 PPIIC&nt - Return all copies to SAN JOAQUIN COUNTY PUBLIC I{ ALTit 3ERVICES (r)� bJfVIROtlYfliTAL HEALTH DIVISION PERMIT/3EfiVlCE3 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 9320 i two AMOUNT DDUEEy AMOUNT Rfmii/rrrED CK CAS`r R(CEi%,EO By DATE ERMtT N tN 1324iRfv ,■s ,{` cU T^ �L IOU y; �G51-�f ") 'a