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s f .=.?PI.7�ITIUN �:?I+ =sIl3LIT SAN .;OAWL iN COUNTY PUBLIC HEALTH SERVICES FNVIRONLENTAL IIEPLTII DIVISION 1601 F. IIAZF1,TON AVE. , ")IONE (209)468-3420 P O BOX 2009, STOCK! JN, CA 95201 11pnS 1 YEAR FRUM_�AI'S IS;�fyQ (Complete in Triplicate) Application is hereby msle to San Joaquin County for a permit to construc'. and/or install the work herein described. This application is wade In compliat.ce with Saa Joaquin County Ordinance No. 549 and 1862 and tie Rules &,A Regulations of San !oaquln County Public Health Services. / Job ALd,ess �l Z' �'!�c�wL j—r----- Cnv �t21J�-_ Lot Owner Name Adhress _-2_'•j1a t" _� Phnne T}1'` Contractor L Address_J�O ,� r2Llcer,se No 7_� 8Pnone "T TYPE OF WELL/PUMP NEW WELL O 'YELL REPLACEMENT 1 - DESTRrJr;T10N it Out of Service,Wetli •L3 - ! - PUMP INSTALLATION 0 SY5 EM REPAIR Ll .)THER 0 Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TA74K SEWER LINES DISPOSAL FLD,____ PROP.LING .- FOUNDATION AGRICULTURE WELL _ __ OTHER WELL__ -OOS/S PS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION!SPFCIFICATIONS- Qr j C,Industrial ❑Open.Bottom C)Manteca O,s.of Well F,cavatron —., Ois.of v'„r Casing — E (I Domestic/Private U Gravel Pack I1 T:e.;• Type of Casing_ SpovI.Catrons 11 Public 11 Other fl Dolts Deplh of Grout Seal Type,of Grout I I Irrigation __Aplwo%. Depth I Esslom ,;.rfac,,Seal Inktallod by y Repair Work Done U Type of Pump _ 11 P. Stale Work Oona Well 001C tction O Well D.amater Sealing Ilst�ria/ a Depth 'v• s Depth_ T__ Filler Hatbr1al'1 Depth ��- f )YPE OF SEPTIC WORK. NtW INSTALLATION I 1 REPAIRU,OUITION T7 D'[STFtU(:TION I I Ivo septic anusm permrttad d pub1.0 wvyer,its available with n 200 feet.) Installation will serve: Residence/Commercial_ Other _ Number of living unite } � Number o�tad�c�ms Character of toil to a depth of 7 test:• _--,___. -Wat r table depth r SEPTIC TANK 0 Type/Mfg Capacrty_._-_.__.r No. Conpartneents PKG.TREATMENT PLT.0 Method 1►f Disposal Distance to nearest: Well Foundation Property Line_ 7 Li ACHING I,:NE LX/No.8 Length of lines =y1 Total length/size, FILTER BED ❑ Distance to nearest: WNI Foundation Property line s SEEPAGE PITS I 1 Depth _ Sus _�� /tl Number SUMPS Distance to neatest. Well J-00 Foundation--al_Z Property L,ne 100 Q DISPOSAL PONDS 0 I hereby certify that I have pteper,;this application and that the work-11 be done in acCU'dance with San Joaouin County ordinances,stab laws,and r•.les and teoclations of tha San Joacuin Crunty ilome owner or licensed agent's signature Certifies the following."I cvhfy than in the perrcrmance of the work lot which this pefntit is issued,I shell not employ any person in such manner as to become subject to workman's conpens lion)awl of California,”CJntfa('tdrs hiring of sub-contracting signahrre Certifies the following:"I Comfy that in the,performance of the work for which this permit Is issued,I shall employ person, •bjeet to workman's eonvenss• _ tion laws of California." The applicant mus call for ell re (red inspections Complete drawing on(*vera#side Signed X___J T,,,.:�� Dab: [7 F DEPA.1 ENT USE ONLY Application Accaptd by ��' �.fj _ _-~'� _ Data Arca Pit or Grout Inspection by _ DateFina)1,1poction�y, `4' Data _ - Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ir-� Services, Crvironmental Health Permit/Services 1601 E. Haselton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT OUE AMOUNT REM-TTED CKa RECEIVED BY DATE PERMIT NO. INiO CA5// . fi/ti-ta lafv,ires, �� O q�-20 FM'.Ile