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a APPLICATION a# . a SAN JOAyUIN COUNTY PUBLIC HEALTH SERI — ENVIRONMENTAL HEALTH DIVISION JAC) # 445 N SAN JOAQUIN, PHONE (200468- P O BOX 2009, STOCKTON, CA 9520 FAC# REMIJ RB t, # (Complete in Triplicate) 1 Application is bereby aoe.to San Joaquin County for a permit to eonatruct andlor install the work herein described. This syylication is Cade in eetwliance vith Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and R%gu]Ations of San i Joaquin county Public Health Services. ,fr , .lob Address �-=-" Q� 1i'c:!! �a�F d'!} f`�� C.,vJe196AJLot Size/Acreage f pyrrwr•a NameAddress �rFi� G!R7dPp— Phpne 00 I } Contiacta T �1.C�( .. Address f d� License Nov -Phone I I TYPE OF W LLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O am1toriAg Well 0 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. •,PROP. LINE .I FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q n Industrial ❑Open Bottom ❑ Mantece Dia. of Weil Excavation Dia. of Wolf Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ �peoiflcatidls 1'I Puhlk 1:1 Other fl Delta Depth of Grout Seal Jia of Grout — I I Initiation _AXxox. Depth I t Eastern Surface Said installed by y Repair Work Dona L] Type of Pump H.P- State well Destruction ❑ Wall Diameter Sealing IMterial A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION L DESTRUCTION F illed it public sewer is P t rn 2D foot.I Installation will swve: Residence-je Commercial— Other Number of living units: -L Number of bedrooms ' Character of soil 10 a ooh of 3 feat: - � � -...,,.water table depth SEPTIC TANK ❑ Type/Mfq Capacity No. Compeaments PKG. TREATMENT PLT.0 �T Method of Disposal i Distance to nearest: Well dkV Foundation _ -_ Property LL-4 :LEACHING LINE No.& Length of lines � Y � Total length/size FILTER BED 1n Distance to nearest: Well o&5CL3—#A: Foundation_,1 Property Line �y _ ^-# --• - SEEPAGE PITS 1 I Depth ltd Sire 112 (, 2e. �T- Number SUMPS K Distance to nearest: Welly Faundaiion 'Yt1��'Property Line F DISPOSAL PONDS ❑ I hereby Cavity that I have prepared thio application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulatiara at iho San Joaquin County Home owner or licensed agent's iignarura anif'Iea the following: "I eanify that in the perlormance of the work for which this permit is iswad, I shah not employ any person in such msnrw as to become subject to workman'%compensation Ism of California.-Contractoy'a hiring or sul}corNractmg signature arldiss the following:"I certify that in the pertormame of the work for which this permit is issued.I shall employ persona subject to workmen's companss- tion lows of Camoonle.- The applicant must Cak for 1 eq aad inspections. Complete drawing on reverse side. Signed Title. Dela: r!! _RWIDEPAJWMEW USE ONLY Appk ation Accerrto0 by Data D rsa �i[a Ph or Grout inspection by Data Final inspection Dy Dat-IA Addltlonst Commrnts: Applicant - Return all copies to: Sail Joaquin County Public Health Services i I Environmental Nealtb Permit/Services 445 N San Joaquin, P O Box 2000, Stkn, 95201 FEE I NFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY D PJERM"'NO. EM rbL I