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APPLICATION FOR PTIWIT SAN €..,AgUIN COUNTY PUBLIC HEALTH b,sftVlC a ENVIRONMENTAL 1LEALTII DIVISION �v , 445 N SAN JOAQUINr PHONE (209)466--342(] sttn P 0 BOX 2009, STOCKTONt CA 95201 LERNIT_..0Idle ,1 YEA19M FI19M DATE I9� LIg ren SCANNT11 p to ill Triplic[Lte) 1 APpiltatlon Ir heretry made to Ben Joaquin county for a permit to construct end/or instep the vork. herein described. This erplication In made in coegliince vlth Ban Joaquin County Ordinance Ifo. 5149 and 1662 and the Rules and Regulations or can Joaquin County Publle Health Berrices. Job Address 251.92 River Road Cloy E,&CnI _ Lot dice/Acreagq �72 Ownsr'i Na%u `1Oe $ Pat Laws n M Address 3827 College View Dr. Jo li .� 0Nrane517—b24- 4, Conhailor Carrier Const Richardndditss _ Llcense No�. h 441868 Phone TYPE OF WELLIPUMP: NEW WELL Q WELL nEPLACEMENT f1 DESTnUCTION ti-Ni of Benita uell I-) PUBAP INSTALLATION ❑ SYSTEM REPAIn 0 OTiIEA O Flonitoring Well [� DISTANCE TO NEAREST: SEPTIC TANk SEWEn LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS L7 Industrial Cl Open Bottom ❑ Manlece Ofa. of Well rxc&vallan ala. of Well Cash,g Lt nomisticiplivale CT Grayel Peck L7 Tracy Type of Cssinp_ gpecilicalions f 111 Public 11,1 Olher fl Delta Depth of G+out Seai Type of Grout I I lulpellon _Appian. Depth 11 Eastern Surlace Scut Installed by nrpeir Work Done LT type of Pump 14.P. Slil Work e or Dons _ Well Vestruction ❑ Well Diameter Be sling Haterlal L Depth Depth ►iller lktarlal 1 Depth TYPE OF SEPTIC WORK: NEW INSTAt1ATION,k1x fiEPAIn/Ant)mON I I DEFAUCTION I I INo septic system errnllted 11 public sewet is available within 200 leel,l q � Insullllr�n will serve: Rtildencs 1 Commercial�• Other (� Humbir of living units: L Number of bedrooms .2 -- Chlrsclir al *0110 1 dellh of I feel: Wooler table depih. 1 n0 i + SEPTIC TANK W Typi/Mid P._ .. L Cipaclly._ L am-g Flo, Compartments �F PkG, TREATMENT PLT. 0 Method of blsposal f Dislance to nesresl: Wall_10 1 Foundation _10 r ^_ Properly Llns —1 f)O+_ Lf ACITING LINE INNo. A Length of iin11 r Total lengthlslri - FILTER BED CI Distance to neaneal: Well .150 Foundation 30 Properly Line stEPAOE PITS 11 Depth Slse Number SUMPS 1.1 Dlsilnce to neared: Well Foundailon Properly Line DISPOSAL PONDS Ll --" I hereby tinily that I hive Inspired this appllc+illon Ind that the work will be done In accolyince with San Joaquin coumy ordinance!, side laws, and rules Ind itguldlons of ihi Sen Josauln County Home owner or Ilcen/ad sgam'i ilgnaluri cerlillii the following: "t certify that In the performence of the work 101 which IN, permll Is [Bitted, I shell not ",imptoy any person In inch manner e1 10 6scowna subfect to worl,msn'e compensailon laws of Call'"Is." Contractor's haling or sub-eoniraciinp donaiurs Millie,the folowing: "I cerllly that In Ihi performincl of the work for which Ihli palm"Is laaubd, 1611411 smpioy persona sublect to workmen's compansa- Filion laws ni California.,, ll Ina sPplkans at a for req lnspyettons. Complels drawing on reverse side. $bed ` Titli: ��ntrr101'nr Oats: FOFt DEPANTMENT USE ONLY Application Acceplid by Dati Arse Pit or Gtoul Inspictlon by iti Find Inspection by r gala 2' Additional Comments: Applicant - Return ail copies to: Ban Jonquin County Public health Services CLQ 44rlroam0Jo IronIloalh Permit2009, con ��o j lid N ileo Joaquin, h 0 pox 90017, Btkn, QA 95201 �O AMOUNT DUE L/AMOUNT REAITIEDNF0 RECEIVED Illy PIR- MIt,NO. initsv rrss law _ -/