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_ ( o plate in plicate) <br /> Application la here made W Sea Jaa tela County pP hereby q C un for • rail to nstruct orad <br /> Y Fe !or lnaceil frit wort hereto d <br /> secrSbM. This <br /> appllcatloo Is bade 1• compliants V1th Ban Jaequin County Ordinance Mo. 549 and 1862 and the Rules ami Rejulattonm of San <br /> Jotquln County Fublle Health 'Services. <br /> JohAddresa 'II:I'lr;Ilr, :Jr• :7 !�.__ �: '! 1'i City -•. r Lot31se/Acreailia it;1 i <br /> - ori,.-•i , :. .. <br /> ih,.l Jul.(\ :r:rl:'ailr:l-r r." 1ti r f. '.r f. <br /> gwner't Name Addrass ,P,f, f , .'.:r ".f'--- `r,• Phoni .�.. y(.;.- fool,. <br /> Contfacla SFr+!tf.0 r.• ( Y s '•1f Redress - - - ---.I'H.r<,' :,�1 "I "r iceate No, <br /> TYPE OF WELL/PUMP; NEW WELL J-1 •-- WELL REPLACEMENT n DESTRUCTIGN ❑Out at Service Well ❑ <br /> .PLUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHZR 0 Maoltoe'loj YaU 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK I "` SEWER LINES r.J r` DISPOSAL FLD.7� PAOP.LINE r, <br /> FOUNDATION ' l AGRICULTURE WELL,—'&—'J OTHER WELL _'"! PITS/SUMPS LLJ'l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST43UCTION SPECIFICATIONS <br /> n Indusinal ❑ Open 8oporn ❑Manteca Dia,of Well Etcavalion �1 r <br /> W � Dv.o}YleA Camirq <br /> x47 Don+eslic)Privit Cl Greve"Pack 13 Tracy Type of Casing -f t' `- Specifics <br /> tfo;lll..�r}i;., - ....�� <br /> I'1 Public fn 011ier nDana Depth of Grout Seat _�r Trpa of Grote t �rT'+:r•1 <br /> 4 l lrnpalion 'E_1 ApFroa. Depth )i,Fasurn Surface Setl Installed by <br /> Repair Work Done LJ Typa of Pump H.P. State Work Dan& <br /> Welt Dntruction ❑ Wall Diartwlat Sealhj Xtterlsl A Dcpth <br /> Depth Filter Hatarial a Mpth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 111 DESTRUCTION I 1 dNo septic asslem permitted if p-414c sewer is <br /> avadabl/within 700 loft.) <br /> In llt":.,on via terve: Raeid-nce T Commercial_ DOW <br /> Numbs. all living unitm: Number of bedrooms ��� t <br /> Cauacter.ter soil m a dapti,of 3 fool:_w <br /> tri <br /> SEPTIC TANK ❑ Type/Mfg Cap�cl -y,� rpyu . <br /> PKG. TREATMENT PLT.:! M,, rt r o ct•,N,I` TM <br /> Dnarue to nearest, Well Foundation Piapariy L-f � y <br /> —SAN JOA(f11m CpIfNTY a <br /> ` - Pttt34tC c YIC 3 <br /> LEACHING LINE CI No.i Length of tinea <br /> FILTER BED ❑ Dia.lnc4 to nearolu Wall Foundation Prcpe ty Lna <br /> SEEPAGE PITS i I Depth --Sire _ NurnMr ` <br /> SUMPS L1 Distaroa to merest; Wet Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby canit)r that I have Firapucd this epplicatior,and trial the wcrk wih be done in accordance,with Sin Joaquin county or6nances.arae lawn• ted <br /> miss and r►pulahora al the San Joaquin County . <br /> Ham&owner or licmnaed apsnt's signature canities the following:1 certify that in the perlarmence of Ili.work for v hich this prmit b'-taufd.I shaft not <br /> employ any porion In such nvnnat as to become subject to vrarkmin'e compensation laws of Cmlifprni., Contractors h'aing ar IuDCanuat,Kg srgr.atwe <br /> c lrti!ies 1!:s to towing:"it#rtitV that in the pit rlorrr:rnc*of the walk far which this permit is isaved,I rha!t frnnloy par*CAI whist io-Wirruin t coryenss- <br /> tion laws of Califv...." <br /> The applicenl rive^• - If all raquir+diy Ipt.cfigna Complete drawing on mend life. . <br /> 5ignad7C.//--- _ -.-.�-� r Title: -.r• !' '1i -' Date: _ <br /> / n FOR DEPARTMENT USE ONLY <br /> A.pplicelron nr t r rill tee�i� Dote -51 /V I <br /> ,. el <br /> - <br /> Pit or Grout Inape_..,:,by / .r Data �' 7 7 r�/Find In"clicn by Dna S <br /> Additional Commsnit' il-" rSit- <br /> ,� <br /> -- <br /> Applicant - Rsturo all coplea to: Sao Joaquin COuat> Publtc Health Services <br /> Savlr"mantal Heallb Pu'mlti3ervtces <br /> 445 N San J!"quin, P O Som 7039, Stka, CA 95201 <br /> 1 � AUOUHT OtJE Ai,tOU4T hEMIY740 CASH <br /> AfC!IYEO!1Y DATE Pf4Mli MO. ��JO' <br /> .1,+11:4 tRrv. ('r, <br /> • tK,4.s t � <br />