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APPLICATION FOR PERMIT SAN WIN COUNTY PUBLIC HEALTH S V`1C .GN V I RONNENTAL HEALTH U I V I S I OR � ' 445N SAN JOAQUIN, PUIONE (209)468-3420 titA P O BOX 2009, STOCKTONO CA 95201 Ir" PERMIT PrtiUIREE]I_ YEAR FRQM DATE (Cal"Plete in Triplicate) Application Is hereby a+ede to Ban Joaquin County for a permit to construct and/or install the work hereln described. This application is made in tovTltince with San Joaquin County Ordinance Ila. 5h9 and 1952 and the Aules and ftegul.atione of Ban Joaquin County Public Health Services. .lob Address "."25192 River Road - City Escalell Lot Hire/Acreagq Ownar'i NsRle Joe & Pat Laws Address 3827 College View Dr. Joplin, fflphOhe 17--624— ConllaElor Garner Const Richardnddress license lion,Ih 44 BbE Phone — TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT I1 DESTRUCTION EI Out of Serrlce Well lT PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ monitoring tfell L7 DISTANCE TO NEAREST; SEPTIC TANK. ,SEWER LINES DISPOSAL FLD. PROP. LINE FOUNuATION A0111CULTUrte WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROREMAREA CONSTRUCTION SPECIFICATIONS EI Induthial ❑ Open Bolcom d Manlecs DI& or f Well Excavation Die. of Well Cooing H Dom4sllc/Privets 0 Gravel Pack 0 Tracy Type of Casing Speciilcallons III Public 1:1 Other fl omits Depth of Grout Ses1 Type of Grout I I hrluarlon _Approrr. Depth I I Eastern Surface Saul Installed by Repair Work Dons U Type of Pump H.P. Simla Work Done _ r- Won Delituellon ❑ Well Diemeler Bailing Material l Deptit V` Depth ►Oiler Material L Depth 1YPE OF SEPTIC WORK: NEW tNSTA1LA1ION,1VX 11EPAIn/AUDITION I l DESTRUCTION 1-1—Wo rmplic system permitled it perblic sewer is available wllhln 200 Isal.l Q\ instelielton will sarbe: Reiidence 1 M Commarctat Other Numb4r of Hying units: 1 Number of bedrooms .2 - ChOloctit at /OA to i depth of I left: _ _"Sand _ Waley table depth } SEPTIC TANK f1 TW4/Mid _ConcrerP P & T. Capacity 15 - No. Comparimenla Pka. TRE41MENT PLT.❑ Method of bhpoael Dltlsnco to nesrsel: Weil 150_ Foundation . 1 n I _ Plaperty Lina 1,0_ LtACNINO LINE Lq No. A Length of IIn44 1 Tolif length/eltl — FILTER 8ED CI Distance to nearest: Well 150 Foundalion .30 Property tlni 8 SEEPAne PITS It Depth Site Number SUMPS LI;- bistlnce to neweal: Well Foundation Properly Line DISPOSAL PONDS L) I hereby cirlify that I hive prepared this applicillon and Ihel the work will be dons In accoftllnce with Sen Joaquin county ordinances, stale laws, end Was Ind regulatlons at chi San.Joaquin county Home owner or Iluna4d sgenl'O ilgnahnl eertifiai the fallowing:"I certify that In the perforrnence of the work fol which this permit It Issued, I sham 1101 "rlmploy any parson In such rnenner to to 64co"lubfecl to workmen's compensellon Iowa of Callfornle." Conilactor's hhing or tub-tonlrscling signstu�4 tertlllsa the following:"I ceriify that In th4 performirnci of the work for which lhfd patmil l/lasubd,I$hill Omploy persona lubf ecl to workmen's compansa- tion laws ni California." Ihe oppiieoal u11 a for req& Inspaclions. Complete drawing on reverie Olde. 131g,4d ATiils: —Lun rar_Y_n.r Dale: - .......� _. a FOR DEPARTMENT USE ONLY Application Attempted by pati 7- Ara■ Ph Of !Foul Inspectlon by its Final Inspection by Dale Addlilonsl Comments;. Applicant - Return all copies to: Ban Joaqutu County'Public Ilgatth Servlcaa $avlroumontol Health Permit/Betviceu 4411 H Baa Joaquin, 1, o Box long, Btkn, OA 95701 1Nfb AMOUNT DUE AMOUNT REMITTED 511 neelivea I!v p TE PERMIT'Np. 11-1IIhrV-1/ea1 ,t a