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APPLICATION c�pp SAN JOAQUIN COUNTY PUBLIC HRALTH SESR&S I�bLL SNVIRONYENTAL HEALTH DIVIS y �� Y AUG 25 20116 445 N SAN JOAQUIN, PHONE (209)4 KM _ NTA P O BOX 2009, STOCKTON, CA 96Z91 1 �.nP91R0[ t -NT WHEALTH Lit EXPIRES 1 FR TE I (Complete in Triplicate) Application is hereby cede to San Joaquin County for a permit to construct And/or install the work herein descrlbed. This appll"ti0a is 4ade in Compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Puolic Health Services. S'ak. A.1 �t-4,ff /hstifil" Job Address 01#V --3 renamed MWR-13 city Lot Size/Acr".ge Ovmar'sNama Address 3-0Y wt-s? 57twTh+cT /�+� _ Phone / DX+t�r.. 1 10 �flw,/N*-. Dr•�dcti E^s/ 69)soY LG 9-ot/1 Contractoror Address License NO._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Art of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well xf DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1 Mameca Dia. of Well Excavation, — Din. of Well Casing E1 Dornasfic/PlNate ❑ Gravel Peck ❑ Tracv Type of Casing )4J.L. szo,,. Spscrfications Il Pahlie FICuter rT Dere Depth of Grout Seal ---7S1 Type of Grout 1 1 Irrigation if�L Appror, Depth I I Easurr Surface Seal Inst,lled by fA6 u Repair Work Done ❑ Type of Pump H.P. Stare Work Dona _ Well Destruction ❑ WON Diameter SeAling Material A Depth Depth Tiller Material 4 Depth TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I MCI saphc system permitted if pubk sewer u C ' w 1< available within 200 fest.l .Z.0 "DFe� rutalationwill serve: Residence_ Commercial_ Other r��e /� Number of living units: _ Number of bedrooms r T� Character of soil to a d rpM of 3 fest: Water table depth SEPTIC TANK - ❑ Type/Mfg Capacny "No. Compartments O -ronsy PKG. TREATMENT PLT. ❑ Method of Disposal .a Distance to nearest: Well Foundation_ Pr � � � operty Line ! b LINE ❑ No. 6 Length of lines _ Total length/size I FILTER BED ❑ Distance to noose Will Foundation _ Property Line �4 tSEEPAGE PITS 1 I Depth `__Silo Number SUMPS LI Distance to menial: Well Foundation Property Lire DISPOSAL PONDS ❑ 1 hereby cavity that I have Prepared this application and that the work will be done in accordance with San Josquin county ordinances, state aims, and raise and regulations of the San Jwquin County Norte owner w liConsad aper.',signature darhsa the following: "I comity that in the performance of the wont Ile which this permit is issued, I shall now empbY any Person in such manner u to become subject to workman's compensation awe of CNHwnis." Contractors hiring or sub-contracting signature Certifies the following: "1 certify that in the performance or the work for which this permit is arouse, I ansil employ persons subject to workmen's compen". tion Is"of Califs" in -��^ The sppbcaht f r/1 r d inspections. Complete drawing on�/1 reverse side. U signed �ltr.% y� Title: , 0J 4 C"Lllwle 7 Dem: _ �� / FOR DEPARTMENT USE ONLY ,.ry Application Actwlod by 1441Ms—e a� Da1s ^f `f3 A Pit w Grout illopwtie by news r _._ Final.., I:.:P:t:on by Dare/ Additional Conmertts: Afplleantf Return all copies to: Ban Joaquin County Public Health Service.Eiriv /-r ./ tftl Health ,V 4481N OSun n Joaquin, P Oe Box t2009,11cee Stkn.CA 95 1 "a`�- V O /it 4,1(- FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By IN CASH. Esu 13N IaN.rrnarM / V /� 3 5V