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APPLICATION - i SAN+.,OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTALAIEALTH DIVISION 445 N SAN JOAQUIN, PH HE (209)46$-3420 P O SO% 2009, STOC TON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED t (Complete in T iplicate) Application is hereby made to San Joaduin county for a permit to a netriict and/or install the work herein described. This application is made incompliance with San Joaquin Comity Ordln&nce No. 544 and 1662 and the Rules and Regulations of San Joaquin County Public Health Ser/Ivi))ces. J J LY-7 7 W 'l �`O'` Cit 1 f 8 r I Job Address � !� � y�7'��'`~�`1 Lot 31 ze/Acres e 2 q3- Owner's Name c• Address °'�'��p►+ono Contractor Address `� License fro. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION Cl out of Service well Cl PUMP INSTALLATION 0 SYSTEM IEP�IR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TAMC SEVVER LINES `-- bISPOSAL OLD. PROP. LINE -S FOUNDATION AGRICULTURE WELL OTHER WELL PIT$)SUMP$ INTENDED USE TYPE OF WELL PROBLtM AREA CONSTRU TION SPECIFICATIONS Cl Industrial O Opeti Bottom © Wmace Dia. of Wei Excavation Dla. of W611 Casing F1 Domestic/Private VUravel Pack El Tracy type of Ca 1iinga s>` r! Specifications I'1 Public El Other Cl Delta Depth of Grout Seal Of Type of Grout � I I irrigation — Approx. Depth I I Eastern Surface Simi Insiblled by f'a'` '"' Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Hdtet•ial a Depth 9 _6,V,�,l .P 2(, we�lS Depth Dior �0 `'L Filler MaterialDepth a TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public "sewer is available within 200 feat.l Installation Wit serve- Residence_ Commercial_, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cir acity No. Compartments l PKG. TREATMENT PLT. Cl Method of Dibpoial Distance to nearest: Wetl Foundati n Property Line LA LEACHING LINE Cl No. & Length of linen total length/size l FILTER BED ❑ bistance 16 neareitt: Well Foundat on Proparty Line SEEPAGE PITS 11 Depth Size Number �• SUMPS LI Distinci+to nearest: Well Foundat on Property Line DISPOSAL PONDS 0 s I hereby certify that I have prepared this application and that the work will be donIi in accordance with San JoAdUin county ordinanc'OS, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, I "shell not employ any person in=itch manner as to become subject to workman's compensiti n 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 p emit is issued, I shall employ persons subject to workman's compensa• tion lawi of Chlifornla." The applicant mu call for all wired I ns.-Complete drawing on reverse ids Signed K Title: l + �" iSJ Date: FOR DEEN -ONLY 3 Ap ication Accepted by Date a :M Pit or Grout Inspection by Date `a — Fin I inspection by Deur i Additional Comments: Applicant - Return all copies to: San Joatpiin County Public Health Services Ehvirobrieetal Health Peri it/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 INFEEFO AMOUNT DUE AMOUNT REMITTED CASH KI RECEIVED eY DATE PERMNIT•NO• EHt3.2440EV.I/A51 r7 EH t42ts