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ApD n 1e mad•C wit unty pty Oetal raLr /or L the YY{���rrtln ed, F [ _
<br /> •�'�a i■ itoaqur� 11u,� 186 he pY�d Ra • of
<br /> r.� uin Couaty Public Health Services.
<br /> Addraaa .� Z4J'�Sa E) �t Citl�2lQ41f11111} t Sire/Acres&* 1 ',,;s;%F, y4�xyr'j~"`;•,' rf
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<br /> • Owner'•N ���f7.�oe:eia�..�6_�t'� �i��,t_��LY�� P >rL��e,�J� , r •r;rte �`;'�;:
<br /> t CanttaciorLNis><i fa7he cu 1 Q+I+4tair -�7!'MSSYf7r'
<br /> ` � r�LL.L,G,( Sir _1_tCOWa o, on
<br /> TYPE OF WELLIi'JYP; NE WELL WELL REPLACEMENT CT DESTRUCTION pout of Serrlee Vell [1
<br /> PUMP IE,STALLATION 0 SYSTEM AEPAM p OTHER C13 MonitnrtnS Va
<br /> Ye11y • .s �, r f � iyl'r .vl
<br /> r i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. 'PROP.LINE •.�, :t� lu°t� °_i1{i f
<br /> ! ' FOUNOAT!ON ._ AGRICULTURE WELL OTH!R WELL PITStSUMPS ;l{,5,°Y
<br /> I ' NOED USE TYPE OF WELL PAOBIEMAREA CONSTRUCTION SPECIFICATIONS
<br /> t —yF—
<br /> ndualeTl rHl ❑ 8ouom C7 Manteca
<br /> Did.of Woo ExcavaGon.�2 Die.of WOO Casing 1 njt r d
<br /> j. .1 11 Dornea[kJPrivttt LiCG[avrl Pack ❑T[ecv Tvpo of L�aain �( y� �Qt{�(a SpoCt icabon• r` =i ;It }
<br /> Public 11 O{hN fT Delta Depth of Grout Sed 4�4�a,r�SAa� 7r of Orou����� .ii�e p f: ��
<br /> hsipallon �-Appros,Do In I I EnNrn Surface Seal Inataa.1dby- E i' +.: 1+�' rK►!-,{
<br /> epais WWk Da+t -(] .-.Type of Purtp �... N.P. �/4 _ Slur Wolk Done [
<br /> a�f �. 1
<br /> WY Destruction Well Divnetar — Stalitsa lsattirial S Depth
<br /> ..•. .,,•• 13�pLA _ _,�i4 stiller)Ltar41 A Depth- __td1A_ {yj� .,j.•
<br />' p r t^ t+ Y�--OF SEPTIC WORK. NEW ikSTAiLATION 1 1 REPAIRIAODITION l I DESTRUCTION i 1 INS lapuc system permitted if public iewar is
<br /> x�j+r ,,rr% ` a teal.within 200 1.101.1
<br />[ jR^f 1' j 1 itu allatian wit wm:' RitMenq Conunerclrl Othir
<br /> F '
<br />'+!y-'•ii' �}�� i�,:. , Numb.of t'wk,p tu,Ita: Number of bedrooms � .j35 Ij•�, i E �, ''t.
<br /> C1166,111,01111 Of soz to.depth of 3 las,: Waist I"depth {
<br /> Y l tar _s t 8EP7iC TAP}K'' E] TypuJ�llp Capacity No.Companamnis 3
<br /> `: .? r " PKG.TREATMENT PLT.D
<br /> its s Method Diapoaal
<br /> r`.,•z' Oimancs to ruses: Well_-- Foundation Property Lint F� 'F t LZ T`
<br /> LEACIiINQLINE LI f7o. i tt th of Lnea
<br /> L nG Total Iength1siee
<br /> '•,�.y:';E FtLTER 6E0 0 Distance to nearest Wsll---- Foundation PropeftyLine
<br /> SEEPAGE PITS I I Depthy r.- t y •1�%j;fir; i;
<br /> Pap —_Site
<br /> SUMPB LI Distsnu to nttg.eah Wall Foundaton —'Propsrry tine 3 „ ��!
<br /> DISPOSAL A FONDS .I r•:i c {.•k,j•ti r,
<br /> L Y l Mrab Csrti that I naw 1 " i ' '' r •f a
<br /> Y h' ape.a vp�+tian and than tip v.olk will W Dant in accoldanca wilt:San Joaquin ca:nty ordinanua,.tats laws,
<br />•.'i?:t�•;�, i*.�=Li, rules and r*otilai"at and San Juaquon county ? ,r,l'�f F<?!
<br /> Hot"taM�{{y, a/fJ..•.
<br /> wnet Of licana•d#pent'.slpnacum Canilita the foto t:no;"I car ily 1hal In ttu parlormence of the work la Y+itkh this permit is iiwed.1 shay r1`�jy,� I, ;,'•Y
<br />'1,',T"-s ;f •,:•': - trttp,o/&,ly'Ptrwn In&"I;manner as to bacame subject to workman's eampemuwn taws of ralif0rnia."COALW ar'■hit" a sub-conuac( � � � r.:•�s+ ° �At
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<br /> tna ew ilanaw•o rE
<br /> f ,_ eenR4&/lt•l'A0*irYe;"I cooly that in the paAormertce of that wosk lot which Ih;P::t is is d,I shall smplay persons wbjecl to worktrrn's eor-rperua oft» 4 4�1T14'e a ttrla :a11 alI rat uir 1 Ik7,a. Cart.lata drewinq on nv ' ffj� p
<br /> ,•. k4 u3t SiGni�X Title ate.
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<br /> FOR OEPARTl.1ENT 178E ONLY
<br /> ?' YApPkallon Accepted by 0ata Area ytr. '+�
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<br /> rl? ` Pit tx Cirwrt I-poctloo by : Date Fled Intpoetbn by ? f�.z Date � .'
<br /> "tt =lY;� '),ddhtontl COrt1nW11i 1
<br /> Agpltt:ant - Retum a,ll'crpiee tol'' Bea Joaquin Coutaty Public Aealth
<br /> 8err:.aa, Yavironneatal Health'Peraic/Betwieea
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<br /> [;i '' ,_ - ,�• ,y` t s i. 1601 Y, AnsGaltoa A-•a.i'P 0 Box"2009_. Stockton _CA 95201- .T - {- ;rf�"
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