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APPLICATION "giltSANAQUIN COUNTY PUBLIC HEAL ENVIRONMENTAL HEALTH DIV, I V 13- 445 N SAN JOAQUIN, PHONE (209 p O BOX 2009, STOCKTON, CA ! PERMIT EXPIRES Z YEAR FROM DA E ED (Complete in Triplicat ) Iy —� E. Applicdtioa is hereby made to Sen Joaquin County for a,permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance He. 549 and 1862 and the Mules and Regulations of San Joaquin County Public Health $ervicfs• r City Lot Size/Acreage Job Address ' �) G n F,� r�t�,,�`r R(ddr s clopV Phone Owner's Name Address �Ia` r Y I'r� License no. Phone 46 8XI Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT {7 DESTRUCTION ❑ put of Service well 0 Monitoring'Well PUMP INSTALLATION 0 SYSTEM REPAIR .L7 OTHER ❑ l C] DIST A{ CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Pe Industrial Cl 0 Open Bottom El Maniacs Dia. of.Well Excavation. Dia. of Well Casing Domestic/Private'' ❑ Gravel Pack ❑ Tracy Type o'f Casing_ ? Specifications ' II Pieblie 1_1 Other 1-1 Delta t. Depth of Grout Seat Type of Grout I I Irrigation } ^Approx. Dept I Eastern; l urface Seat-Installed by Repari'Work Doris 01 Type of Pump H.P. State Work:Done_`�- Well Destruction Q Well Diameter Sealing Material i Depth U ` Depth Filler Material i Depth 1 TYPE Of SEP,TIC WORK;--NEW INSTALLATION I'`I--'-REPA9R/ADDITION I I 'DESTRUCTION l I (No septic system permitted if publicse r is y available within 200 fest.) i In sia�ibiion'willse`nie: Residence Commercial ; Other Number.of-living tits: Number of bedrooms Charactef of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,,❑ Method of Disposal t., Distance to clearest: Well Foundation i Property Line L` jLEAFAING'LINE ❑ No. 8 Length of lines To rI length/size 'FILT,ER BED ❑ Distance to nearest: Well `` t Foundation Property Line ,SEEPAGE PITS it Depth Size Number ? v :SUMPS LI Distance to nearest: Well Foundation Property Line ;DISPOSAL PONDS ❑ ii 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 ,rulet and regulations of the San Joaquin County ,Home owner or licensed agent's 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's compensation laws of California."Contractor's hiring or sub•contractirig signature ;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." gThe'applicant mu�cail �all,"u�iredinspertion Complete drawing on reverse side. .,Signed ' Date: FOR DEPARTMENT USE ONLY i Applicatbn Accepted by Date Area �f y 0, r At or Grout Inspection by to Final Inspection by 0 Date Additional Comments: ;Applicant - Return all copies to: San Joaquin County Public Health Services ; . Environmental Health Permit/Services ' E 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 , FEE 'AMOUNT DUE AMOUNT.REMITTED CK 0 CASH RECEIVED 9Y DATE PERMIT NO. INF . EH13-24IREV.I/nsr� � •t� o lO�f 4/ u EH14•Se I- .