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t s APPLICATION SAN JUAfdUIN COUNTY PUBLIC HEAL ENVIRONMENTAL HEALTH DIVI I 445 N SAN JOAQUIN, PHONE (209 Ar- W3#20 st P O BOX 2009, STOCKTON, CAIt PERMIT. EXPIRES 1 YEAR FROM DA . (Complete in Triplzcat ) NN,v/ Application la hereby ma4e,to San Joaquin County for a permit to construct and/drhEEal t � . 549 and`T and the Rules and Regulations of San application is made in compliance vith`San Joaquin County Ordinance No s Joaquin County Public Health Services. } a ` Jab Address !.' rte' ' ( ' ° 1` l .I City C- t"C. 47 40" f" Lot Size/Acreage 0 190 r: 7 '•, gyp.. t Owner's Name 4k 1 `�1k Address 3 1 6vU ' Phone :1 .� j Contractor . Address_ � License No. Phone _ TYPE Oi WELLI UMP: '1, NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service ti1e11 ❑ PUMP INSTALLATION S SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ DISTANCE TO NEA-REST: !SEPTIC TANK SEWER NES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROS 14EM�Ai; q CONSTRUCTION SPECIFICATIONS F1 industrial Open Bottom ❑ Mantee`ca`ar— Dia. of We Excavation � � Dia. of Well Casing Cl Domestic/Private Gravel Pack ❑icy a' T );e of Ca Ing_ Specifications �,. F1 Public f,� Other n D9t4a D'e ih of Gout Seal 1 :C ? --Type of Grout I i Irrigation Approx, Depth I I Eas k . 0 --`-ce 5e�1 installed by Repair Work Done 0 ype of Pum I f P F H:P. State Work Done , Well Destruction ❑ Well Diameter -`Searing` erial a Depth ... Depth Filler Mdtgrial b Depth .....-. . i : , TYPE OF SEPTIC WORK': NEW INSTALLATION ! I REPAIR/ADDITi .i I ._.PS—1 lk- .czcthLd..l_iN�SVAtic s GM- 1 --- perm'ttnd if pubG sewer is _�_ _.axailap�e w' 2�B t►,1`' Instaliatiaii will erve: Residence rcial_ Osf+er Y _ Fit' Num er of li vr'n pphs• __,Numbar�f..bedraoms--ate;—,,.,� ___.-.. - ...._.._._._._._..�..._-- 1-- � i `� I Chartactor of/Oil'+to,a depth of 3 feet: 3y4 :, C t Z LL r:y t� Water tal;iwdept SEPTIC Y � r � Type/Mfg Capacity No. Comlpanmenta�`? PKG. TREATMENT PLT. C} 1. Method of Disposal;' 1 Distance-to nearest: Well Foundation Property Line- i -- 0 1 LEACHING LINE Cl No. & Length of lines d _ Toral length/size FILTER BED F1 Distance to nearest: Well Foundation Property ....Line � - t SEEPAGE PITS Depth _L_ _ Size , Number ._ SUMPS LI Distance to nearest: Well 1�` Foundation Pro ' DISPOSAL PONDS El Party Sena j I hereby certify that l have prepared this application and that the work will be done in accordance with f6 U it �fi�Ylti nonce 'st$te laws, and rules and regulations of the San Joaquin County t f�?f�? , "A,-j iiGc",� Home owner or licensed agent's signature certifies the following: "I certify that in the pertgrmance of the work for which this per�nii is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject t9 workman's compensa- tion laws of Ca(((lR111II!AAAAAArnla," 1 The applicant rrlcrst call for all e i 11 ins " / 4)} h pQ � mplete drawing on reverse side. , Signed X '~' Title: Date: - .; 14 " FOR DEPARTMENUSE ONLY J 1 Application Accepted by n Date r �,-. Area �- rPi t or Grout Inspection by - ! r Da e , %� 6. ~ # l Final Inspection by �'�-X D- > 1 Additional Comments: � 5 �, k Applicant - Return all copies to: San Joaquin County Public Health Services (,r .1' �� j"�� Environmental Health Permit/Services t 445 N San Joaquin, P O Box 2049, Stkn, CA 95201 .. FEE PAEM REMITTEDINFOAMOUNT DUEOUNT CK H RECEIVED By PATE PERiMiT'N0. y EH 13-21 IREV.ISI EN t1yC !Vh k.