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06-21-1993 02: 17PM FROM TO 14084581509 P.02 APPLICATION FOR PERUIT SAN JOAQUIN COUNTY PUBLIC HEALTH ENV I RONILSNTAL HEALTH D I V I S ION 445 N SAN JOAQUIN, PHONE (249)469f��' fl',1E1'4TALHEALTH SERVICE _.- F--0-.-sow-aQoa, sTOcgTo�vr 1 CA ssaa1e� i4.RIM! PERMIX MIRES 1 YEAR FROM DATEIBSLJM -8 PH 1; 33 (Complete in Triplicate) Application to hereby ■oda to tea Joaquin Country for a permit to construct and/or instau the varlt herein described. This applieatiou is eM40 in compliance with San Joaquin County Ordinance No. 544 and 1862 and 4he !toles and Regulations of San Joaquin Cotulty Public health Servit:es. rtrJrq,' Vf W, Address City Lot Size/-Acreage _ . ir7s �% l Addie:: ' � 010 - n dvrMr a Narns ROX $4 Coniraclor Afy i't AtltlrassJt� ! r � .License No. 4-6-6—Pholle TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPE_ACEMENT fel DESTRUCTION irl Out of ftrvice Veil 0 PUMP INSTALLATION P SYSTEM REPAIR ❑ OTHER monitoring well 13 DISTANCE TO NEAREST; SEPTIC TANKPAIN FOUNDATION GAI LL WELL /S INTENDED USE TYPE OF WELL AOSLEM/IREA CONSTRUCTION SPECIFiCAT10 0 Industrial ❑ Open tinhorn ❑ Manteca Dia, of Well Excation via. of Wall Caning 0 t30+neetic/Privies L`i nye! Pack C3 Tracy Type of Casing_ J Specifications I'1 P„blie 1het rl Delta Deoth of Grout $Gal -- Typo of Grout I I Irrigation 44L Appron, Depth I I Eastrrn Surface Seryl Instatfad by Repair Work Dons U Type of Pump _ H.P. State Work done _ Well Destruction O Well Diameter -- -- Sealing 1Ktarial rt Depth Depth Piller Material iti Depth TYPE OF S PTIC WORK: NEW INSTALLATION I 1 REPAIRIADOITION I I DESTRUCTION i I iNo septic system parmitled it public Bawer is available within 200 feet.1 Installation will verve: Residence— Commercial Other Number of living units: -_____ Number of bedrooms Character of soli to a depth of 3 feet: _ Water table depth SEPTIC TANK 0 Typ>r1Mtg .__ ____ Capacity No. Cornpertmentta PKG. TREATMENT PLT,0 Method of Disposal OMunce to moorairt: Well T Foundation Property Line. LEACHING LINE Cl No. A Length of linea Total length/size FiLTER BED 0 Distance to nearest; Well Foundation Propeny Line SE£PAGO! PITS 11 Depth Sire -.,Number SUMPS 0 Distance to morttst: W"�..� Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state Ia+w$, and rules and regulations of the San Joaquin eonoty Horne owner or licensed @Wt's aiQnatu►e certifies the following: '"I cortity that In the pe,forrnance of the work far which this permit is issued, I "If rat smpltsy any parson in such rtrnrler ss to became subject to workmen's Compensation Laws of California." C.ontraclof's hiring of subcontracting sioneture esrlilles,the febwing: "i certify that in the performance of the wort,for which this permit is issued,I shall employ persons subject to workman's compensa- tion testae of Callf nulls.'• The spokant must cep for an rwqyf_pdi sI„ctions. Complete drawing an raver a side V! Signed Title: n foo �m Data: y /f FOR DEPARTMENT USE ONLY Application Accepted by _4''r _ Date Area rte' f►k or Grout Intpaetbn by Date ' r Final inspection by Dale -:'-�AddRbnaf Comnrnts:/� y n.+ + Applicata - Return all copies to: Stn Jaaq County fiu4110 Hesit Services [] Ba.ironmental Health pezait./Serricea I �- 445 H Sen Joaquin, P Q Box 3049, atkn, CA 95201 INFOfee AMOUNT DUE AMOUNT REMITTEE' t�,e`11;It ReCEIVED BY /DA'ft 1#RMFY'No. . fH,i.isrlrsY-,Cass �� f ! /7�f7' PA: tr/m,A? fr- /!?rya TflTai D MI)