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c � _ APPLICATION _ SAN JOAQUIN COUNTY PUBLIC HAALT �rL' '= ENV IROUWTAL HEALTH DIV I �. 445 N SAN JOAQUIN, PHONE (209) � {T - P O WX 2009, S`TOCKTON r CA �S # REWIT EXPIRES I MR FROM U T LU - (Complete in Triplicate Application 1s hereby at"a za Jan Joaquin County for a permit to construct etridior install the work herein described. Tt71s application is made " ccapll"ce with San Joaquia Cour<sy Qrdin4nee No. 549 and 1862 and the Rules and Regulations of Jan Joaquin Cokmty Pahllc Health seervices. f� l Job Address S� 0 +fT u R }f 1tiC' City ��Z AJ Lot Slze/Acreage a Owner's Marne C"irarlpr - 11 r7�►- \�.A►(IC;•`E Acid ress Lice ose tea-2- t I A Piton, TYPE OF WELLfPUMP: NEW WELL ❑ WELL REPLACEMENT- fl DESTRUCTION G out of Service Ye11 0 PUMP INSTALLATION 3 SYSTEM REPAIR ❑ OTHER C` Manitaring well p pi5TANCE TO NEAREST: SEPTIC TANK SEWER LINES � AlSP05pL FLi}, PROP, LINE FOUNDATION AGRICULTURE WELt OTHER tWEUL PITSISUMPS INTENOESl USE TYPE OF WELL PROBLEM AREA CONSTPUCTION SPECIFICATIONS Ci Indw[raat ❑ ❑pan Sortm 17 fiA oantaca ow of Well Fxcavavon Dia- a"YPUwig� {'I Cornsstkc;Privaee C1 GrAvel Pack C1 Tracy Type at CasingSpecifMCIE {1 Pirbfie 1.i Qrher [Z Reita Depth of Grout Seal Type I Irnlyatgn -- Approx. Depth I f Easisrn Surface Said Insial6id by �J ,] kJ Repair Work Done i_] Typo of Pump R,P- Stals Work pone_ SAN JOAQUIN COUNTY Well Orstruc6on 1:1Wahl Oiarrwer Seslibg 11a:.erial G Depth pLJBLIC HEALTH SERVICES Depth Pill-pr sl►t,erta3 i Depth ENViRONMEN AL HEALTH MVISI( TYPE Of SEPTIC WORK: NEW INSTALLATION , REPAIRIADMTTCN : DESTRUCTION i 040 aepTtc syVero perrrituod it public iawir is Avaatablr within 200 laet.l Installation will verve- Restden4e-k!� Co+nmercial ther Number W Imno units_ Number of roams TY Chsaat:tar of F4M t4 i depth at 3 feet: _,Water table depth SEPTIC TANK fJ C&pacity'� 6L No. Comparuevents PKG. TREATMENT PL7.ED i Method o7 afip�asi Distance to merest; We); _ Foundattoti Property Lire LEACHING LINE ii1 No. 3 Length of lines Tptat Wngthfsae FILTER BED ❑ Distance to naa+sst: Well LCt foundation Property Line SEEPAGE P67$ I I Depth Sete Nurnbw SUMPS LI Distance to nr sreay. WaH Foundation _ Property Lima CISPOSAL PONDS 0 1 hereby Cert4v-that! hays prepared this application and that the work will be done in actardance with San.Maquin county ordihancas, state laws, an ruhra and ragulapons of the San JoViluirt County Home owner or tic"b4d agent's signotufv certifies the loaowing. "I certify that in Lha per1cwmance 01 tha Werk for whcch this permit is Wood. I shalt not r employ any person in such manner as to bacons 3ub;6ct to wamman's comoenssti"IAwa of California"Contraetar's#tiring or sub-cVntricling signature Carl it 169 the fogewirtgr"1 camfy that in the pofmance of the work lar which This PB+rN?is tesueld,I shell ampivy pararns aaabjaet io woArun'a Compania• tion ittwa of GRfi}4rnia." orf The atppileant t* B for OR r uirod+ prt►rrtians. COMPlste drawing on revarea s+da, Signed Z w T;tb: *;6,L- i? �D• Hate- FOR DEPARTMENT U5E ONLY Appkatian Aceyptec! by - _ - Date as PIt or Grout lnapsction by pate �__ _____ incl in,speclion by Qate Addit+onyl Cammants-, C J Applit-atrlt - Return a]I Copies to: San Joaa,uin Counry Public ffeaith Services - Fnvironmental Hesith Permit-/Services 943 N S,tn .Tor;quin, P a Bnx 2009, St:kn, ('A P5 1 S � FF �; FEE AMOUNT DUE AMOUNT AfMitTEu 4A- INiO CASH REGEIYED 9Y _ • fN 15-7f lilEV.i! 6, I„f1 {'t �y_ �'Id l.id E Ti-76 r 1[J[JLL [1!V�-Y'IT •lhV^r"�