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APPLICATION FOR PEItM11 SAN JOAQUIN COUNTY PUBLIC IiEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE_ , PUONE (209)468-3420 P O BOIL 2009 , SI OCg1 ON , CA 95201 UN-NEVOCA Pl E FERNI T Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described This application in made in compliance with San Joaquin County Ordinance Igo 51,9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Jnb Address �Q Ott 5T 1 YY1 5 CM::N.. SAY'- City SSO_G_CZt7-n- Lot Size/Acreage G1 Owner s Name Address Z$.2 9 P h 0 n a 4 S&96 Contractor Z_,)eS'T E.tit Address License No /NJ 14 Phone TYPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION f-I Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER frit Monitoring Well C� > > I ►.+- PROP LINE 2_5Z_DISTANCE TO NEAREST SEPTIC TANK � � t,•.t SEWER LINES ir1o��5 DISPOSAL FLD FOUNDATION 102vJ S AGRICULTURE WELL? S ►y. OTHER WELL> m i PITSISUMPS Ct zS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 1 Industrial O Open Bonom 0 Manteca Din of Well Excavation Dra of Well Casing f I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing__ Specifications I I Pithtic 1"1 Other f-1 Delta Depth of Grout Seal _Q-1 0 Type of Grout Set-L—r, t �fr.,ps 1 I Irnpauon _ Apnrox Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo sepuc system permitted if public sower is available within 200 feet I Installation win serve Residence— CommeTaal— Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK 0 Type/Mfg Capacity No Compartments PKG TREATMENT PLT CI Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE 0 No & Length of Ernes Total length/size FILTER BED 171 Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number . SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws and rules and regulations of the San Joaquin County Home owner or licensed agent a signature certifies the following I certify that in the performance of the work for which this permit is issued I shall not employ any person in such manner as to become subject to workman a compensation laws of Cail{OTnia Contractor s hiring or sub contracting signatuir certifies the following I certify that in the performance of the work for which this permit is issued I shall employ persons subject to workman s compensa tion laws of California The applecall Ior an requiredinspectionsComplete drawing on reverse side Signed x_ -ust�, Tell, Pr es f A e wc Date _ALAL { FOR DEPARTMENT USE ONLY 9r(� —Fr/ Application Accepted by Date Area Pit or Grout Inspection by Date, Final Inap etin by AdditiatrRI Commanta AQ [ war'•-c �' CYC 6l �� Applicant - Return all copies to: Ban Joaquin County Public Health Ll Services, Environmental Health Permit/Services r �� 1601 E Hazelton Ave P 0 Box 2009. Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED cr CASH RECEIV D BY (�/A77 DATE q/� PERMIT NO Ell i37rrnryIt"si S I ~11/1 /'�rL � 77✓ Fit S4 zE V (_]LJ /w ` ` LAG