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f uNT Mit AMOUN• allairf 10 BS INFO CASH 7 _____17;.• • I DATE A PPLICATION FOR PERM I T SAN JOAQU I N COUNTY PUBLIC SF.R V ICES ENV I RONUE; Fr AL HEALTH DIVISION 1601 F.. IIAZ ELTON AVE. , PBON ( 209 )468-3420 P 0 BOX 2009, 3'mo—A , CA 95201 EXPIRES ..)33.113_,FRO11 DATE 1SSUE:P. (Complete in Triplicate) Application le hereby made to l.ao Joaquin County for a p.rnit to const -uct and/'r Install the work herein described. Thic al.7ilication is made in compliance with San Joaquin County Ordinance Be. 549 and le62 and the Pules and Regulations of San Joaquin County Public Health Services. r Job Addrets 71-21,) Lt) c.viSITX tot 1417,-,Acr.-fte. %•."17T'nfrl_F".ame" ' owners Name *LW" LA- \-3- Arthie„ , ,.. ., ,4562,"1:7,4„ atIP- c.t t.04 Poe.% TYPE OF WELL. PLIMP NEW WELL 7 Vs; L; PEPL ACP.. '.• VEST AUCT ION NOW. of Service '.., i PUMP INSTALLATION :7 SYSTEM PEPAIR I. OTHER 7.: Monitoring Well DISTANCE TO NEAREST SEPTIC TANK _ _— SEWER 1.1 N1S _ _ _ _ . DISPOSAL ELD PROP LINE FOUNDATION ___ ___ AGRiCLICUIIE WE-L — OTHEP WELL PITS/SUMPS a •I INT ENDED USE TYPE OF WELL PROBLEM AREA (INS' RUCTION SPECIFICATIONS , ( . Ind .Eriai 0 Open Bottom (.-1 Manteca 0.., CI wen f ecavatron ___ _ Pa of Weti CAs,ng ( ')c.nestic/Priyate LI Gravel Peck i • Tracy Tina Of Cuing ____ _____ _—__ . Specitcations-, ... - Putrec • , : Other 1 1 Delta Depth of Gtt Seat __ _ T r ue of Grout fit *ppm. . Depth I Eastern Surface Seel Impelled ns e •• I ea., r ar i C. • Stave Wove DOM) _ Installation will serve - Residence — Commercial _ Otho• Number of thong units _____ Number of bedrooms _ Charc:fef of to.1 to a down of 3 feet' . — Water table depth SEPTIC TANK i 1 Type/Mfg _, .. Conicity.— -- No Compartment% il Method Of D.Sposal PKG. TREATMENT PLT _ FOUntial.on _— eioperts Lin* —.— ' No. 4 Length of lines Total length. sire Distance to nearest, Well Echo nation — Property Line LEACHING LINE FILTER BED SEEPAGE PITS I I Depth _ ,__ __Sue _____________._ Number _— SUMPS 1.1 Distance to nearest Well ____ Foundation ___. _ Property Line ---__ DISPOSAL PONDS (-1 I hereby cortilr that I have quipped this eoplicanon and 91.0 the rdcfh o.,11 tie tic)" .11 acCt.rdrr Ce with San Joat.,,iin county ordinances. state laws, and rules and feguletions of the San Joaquin Count' Home owner or licensed a9ent4 signature conifers the following 'I -end n the reuro.reence a' 'tie work fix which this permit is issued, I shaft not employ any portion in such manner as to become suL:int to woirme,, s co. ...ration taws of Cal•lii-rnie Cnotractor's hiring or sub-contracting s.gnature certifier the following 'I certify that in the performance of the won. fur *hitt. s permit ,S ...wed I Ina i employ persons subiert to workmen's compensa lion la s of Californa The applicant must call for all required inspections Compiets drawing on worse so* ( I s y i " -Signed X `<.--....----":-'•-''''--; i lie ---, f \ fOIACITARTMENT USE ONLY Dale - C‘..- .- CI, 4_, • 1 1 ,_ 41 - . 1 1 '44 ;-- - -- Date I met Inspection by ...- . --- Date / 1 init iation Repair Won. Done 1 Type of Pump SUN H P Sealing Material epth Well Destruction Well Oiethere, _ _ Depth _ ______ Filler raterial 4 Depth _ 1 voE OF SEPTIC WORK NEW INSTALLATION 1 REPAIR , AooinoN • nesnaticrIoN No septic srstem permitted if public sewer Tis availably within 200 feet.) Distance to nevelt Application Accsoted by Pit or Grout inspection by Additional Comments / it/ I / ' Ar.,.1tennt Heturn all coples to: an .:caqin Lounty Publ.:- Health Serviceer Knvircnments1 Health Permit/Services :c01 E. Hateltou Ave. P 0 Sox 2009. Stockton. Of .1 • :1 'A 95201 n.•_1, .6.cd MOAT NO