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APPLICATION FOR P5RYI y4 SAN JAQUIN COUNTY PUBLIC HEALTH �f ENVIRCNMENTAL RFALTH DIVIS QQ� uu L/3 7 wN 445 N SAN JOAQUIN, PHONE (209)�0,4,n P 0 BOX 2009 , STOC3TCN, CAIN I }fin PERMIT EXPIRES 1 YE FROM DAT (Ccmnlete in T_ipiicate) S Appl cation is hereby made to San Joaquin County ror a ;>erslt to construct and/or instal., the vork herein aescr Sea. •.in application is aside in ct>epliance vith San Joaquin County Ordinance Vo. 549 and 1862 and the Rules and 3egulatlons of San Josquln County Public Health Services. Job Address S/7-Z S-0 �1,.GIeV 14 LL ery Rd City �70�Jc v1Lot Size/Ac-eage Owner's Name, /�T/�..� /-/L�YO&fi Address nS�sr ✓41V 1941fp /rey Phone Contractor 191Y7�f L1�y V 3,-IY Address 60l'Z License No. yy��l Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT to DESTRUCTION 0 Cut of Service Yell ❑ PUMP INSTALLATION ❑. -- SYSTEM REPAIR C OTHER :❑ Nonitoriag ,rel` C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. (LINE _ FOUNDATION AGRICULTURE `NELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industnal ❑ Open Bortom ❑ Manteca Dia. of Well Excavation Dia. of Wait Casing ❑ Domesoci Private ❑ Gravel Pack C Tracy Type of Casing Speafcetions _ I') Public fl Other fl Delta Depth of Grout Seal Type of Grout I I Itngatwn _Approx. Depth I I Eastern Sudsae Soul Insralloo by r , Race,, Work Done U Type of Pump H.?. State Work Done _ V1 Well Destruction ❑ Wall Diameter Sealing Material L -epth Depth TS`ler Material i Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION/r REPAIRIADOITION I I DESTRUCTION I I (No sepuc system pa wiled J Public sewer is available within 200 feat.) C Installation will serve: Residence L Commercial_ Other Number of )weep units: _/ Number of bedrooms 3 Character of soi to a depth of 3 feet: ' Wallis Water table depth SEPTIC TANK. Q Type/Mfg �XP CAfr PfL Capacity J�OCO No. Comparmann n PKG. TREATMENT PLT. ❑ Method of DisposM _- --Divorce to_nearest: Well PL'YJ a Foundation �O _Proparty_Lill _- LEACHING UNE gf No. 6 Langth of lines — Sar Total length/size / FILTER BED ❑ Distance to neerest: Wait 00 Foundation yoi Property Line Svc SEEPAGE PITS j4 Depth Sim �6�i O�r9• Number �' 3 SUMPS LI Distance to nenest: Wed OD' Foundation Property Line Soo DISPOSAL PONDS ❑ 1 hereby certify that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, aceta laws, and rules and regulalioro of the San Joaquin County Homs owner or licensed agent's signature Cernfiee the foil vng: "I certify that in the performance of the work for whltrl this permit is issued. I Mall not employ any person in wch manner es to bacons wblect to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: '9 conity,that in the performance of the work for which this permit is issued. I.ahall smDloy persons subject to workman's compenss- ran laws of California." _. The applicant ^nyt cam for aq�requKed inspections. Complete drawing on reverse side. Signed X �L•E"/r �rY Ttle: Date: FOR DEPARTMENT USE ONLY A ion Accepted by Date ' i / A Z pit G�(�,rUt bapection by / Date_ Final Inspection by '� Data %V AdLIomnanti: _ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 / j f INFO AMOUNT DUE AMOUNT REMITTED CASH KECEIVED ey DATE FERMIT NO. Fw u.i