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APPLICATION:-WR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 P•0 �%L2009AVS9)468 TOCKTON, CAE. , PHONE 95201 PERMIT %P RES 1 YEAR FR D T ED (Camp3.ete in Triplicate) Application is hereby made to San Joaquin County for afI rpermit to construct and/or install the work herein described. This 1Y application is made in compliance with San Joaquin Co u ty ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. F 3"t$-1 Q, — C�60 I. L I r^t� I. City� Al Lot Size/Acreage 1 /t Job Address tri n {c� L Address e1�r✓S ICJD• Phone �� Z Owner's Name �� — Ir ntractor Address di License No. ��— Phone WELL REPLACEMENT ❑ DESTRUCTION C"1 Out of Service Well ❑ NEW WELL ❑ TYPE OF WELL/PUMP: ryj OTHER ❑ monitoring Well ❑ PUMP INSTALLATION ❑ F SYSTEM REPAIR C1 SEWER'�LINES J�.�.-- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TAN!( AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing I Cl Industrial ❑ Open Bottom ❑ Manteca 'I' Dia. of Well Excavation { [_} Domestic/Private ❑ Gravel Pack D Tracy dSpecifications Type of Casing Type of Grout , i'1 Public 1-1 Other Cl Delta Depth of Grout Seal Approx. Depth I I Eastern !I Surface Seal Installed by 11 Irrigation H P ,. State Work Dane Repair Work Done L] Type of Pump Seaiing Material & Depth Vftf.Destruction ❑ Well Diameter Filler Material 6 Depth f Depth JNo �k TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 .REPAIR!�DDITION DESTRUCTION I 1 availableiw thin 200 feet.) if public sewer is iI 4 Installation will serve: Residence Commercial Other k + f� Number of living units: ` r Number of bedrooms j II Water table depth I Character of soil to a depth of 3 feet: C �` _CYC'• Capacity � Na. Compartments SEPTIC TANK. � Type/Mfg _ y Method of Disposal PKG. TREATMENT PLT. ❑ ' f Foundation S Property Line f r_y I ST IWd Distance to nearest: Well LsL - I 01 Total length/size,-044 LEACHING LINE ,-044No. & Length of lines FILTER BED Cl Distance to nearest: Well Foundation„ -- — Property Line SEEPAGE PITS st'tl Depth Size Number SUMPS Ll Distance to nearest: Well -rd Foundation Property Liner ISPOSAL 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 1I Home owner or licensed agent's signature certifies the followings["l 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's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the woA for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California."/Ss 7M j fia applicant t call/for all equked inspections. Complete dibwing on reverse side. Title: Date: Z igned ' F R�DEPARTMENT USE ONLY i Date Area Application Accepted by Final Inspection by Date Date Pit or Grout,Inspection by i Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services, Rnvirmimental Health Permit/Services n 1601 E. Hazelton!Ave., P 0 Box 2009, Stockton, CA 95201 1 FE CK RECEIVED By DATE PERMIT'NO. i` IN AMOUNT DUE AMOUNT REMITTED CASH _ �1] { . EM 1324IREY.tin5i Q�( d—�I � tin � Jie % 4 ! �l fH 1440