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APPLICATION SAM,, jAQUIN COUNTY PUBLIC HEALTH _.�RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 (Complete tri Triplicate) Application t by :mg�L�det r o the or herein descrl ed. This appll npliance with San Joaquin Cc y Ordinance No. 549 nd 1862 and the latio of San Joaquin Counith Services.^ �/ m Mn A CL� C�� City of ' ze/� s8e �1 • +� JVu amu.•, vas - - — - — - 1 � � 4LYA Phone `► `a✓� J 1 5 Owner's Name -� ddress 'n LContractor�� `[ S Addr Phone TYPE OF WELL/ MP: EW WELL ❑ WELL REPLACEMENT DESTRUC ION t of Service W 1 ❑ PUMP INST LATION ❑ SYSTEM REPAIR 0 HER ❑ (1) itoring W 1 DISTANCE TO NEATEST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ SUMPS INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCT N PECIFICATIONS----- If R Industrial ❑ Open Bottom ❑ Vlanteca Dia. xcav ton Dia. of Well Casing V FI Domestic/ Private ❑ Gravel Pack Trac Type of asing- Specifications I'1 Public (1 Other alta Depth f Grout Se I Type peGrot I I Irrigation _ Appro . spin 1 I tern Surf a Seal Instal ed by C eri Repair Work Done Ty Pump H.P. State Work Done _ Well Destruction Well Diameter _ Sealing terial i Dep De t -- 11 i 1, 1 in IWAterial i Dept TYPE OF SEPTI WO K: NEW INSTALLATION I 1 REPAI /A DITION I I DESTR CTION I I (No septic syste pe ed it public saws is available within 2 feet.) Installation will serve: Residence _ Commercia Number of living unit : Number of bedroo ;L\ Character of soil to a pth of 3 feet: star table pth SEPTIC TANK U Type/Mfg _ opacity No. Comport nts PKG. TREATMENT PLI. ❑ Method of Di oral Distance to t: Well Fo dation Property Line LEACHING LINE No. & Length of nes Total length/size FILTER BED ❑ Distance to ne est: Well Foundat n Property Line SEEP E PITS I I Depth Size Number SU PS LI Distanc to nearest: Well Foundation Property Line DIS SAL PONDS O tLE I hereby certify that I ha a prepay this application nd that the work will be done in a cor ante with San Joaqut u ty ordinances, s ate laws, and rules and regulations of a San Joaquin County Home owner or licensed gent' signature cenifies t e following: "I certify that in the pe forma a of the work for which his rmit is iss ted, I shall not employ any person in suc nner as to become su ject to workmen's compensation la of Call rnia." Contractor's hir ng or s b-contr ting signature certifies the following: "I c ify that in the performs ce of the work for which this permit i issued, I hall employ persons ub to workm n's compensa- tion laws ornia." Thea licant mu t caf or II equir ins ctio .Complete dry r%se side. r Signed Title: --�, Date: `l G S FOR DEPARTMENT USE ONLY Application opted by Date Area Pit or Grout ction by Dat Additional Comments: Applicant - Return all copies to: San Joaquin County�ub'TiL^Herl-tlr-S-e-r-vi-sos -- Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMIT- TED ED CASH RECEIVED BY DATE PERMIT NO. EM 13-24 IREV. t i R e EH 14-20