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A� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> likMIT <br /> EXP RES 1 YEAR FR M DAT <br /> (Complete in Triplicate) <br /> tl <br /> Application is hereby leads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San ,I <br /> Joaquin County Public Health Services. <br /> Z _ City Lot Size creage 7 )L— <br /> Job <br /> L -- <br /> Job Address _I ZSR <br /> Address Phone � <br /> Owner's Name n - - _ <br /> �3 /4 Phone t 75r —211 <br /> o. <br /> �- T-.��I.------L-'cense N �z.��-2---1-- <br /> Coillractor L- -_�Z d - <br /> `WELL REPLACEMENT (7 ; DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPEjOf WELLlPUMP: NEW WELL ' -----WELL Monitoring Well L3 <br /> PUMP INSTALLATION Q <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> l i ._` SEWER LINES — DISPOSAL fLD. PROP: LINE _ <br /> DISTANCE�TO'NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ; <br /> s� i <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM (CONSTRUCTION SPECIFICATIONS y r. <br /> FT Industrial pen Bottom ❑_Mani - rDia.lof Well Excavation Dia. of Well Casing <br /> Type of Casing eLl Specifications �� <br /> [l'Domestic/Private ❑ Gravel Pack ❑ Tracy d <br />' I'1 PL i [I Other "+`(l Delta (Depth of Grout Seal � �� Type of Grout <br /> &IKrr;ipation ..Approx; Depth l I Eastern 'Surface Sea{ Installed by t ' <br /> NZ <br /> Repair Work Dane 0 Type of Pump H.P. 1 State Work Oone <br /> SealingMaterial & Depth I <br /> Well Destruction ❑ Well Diameter I <br /> ` <br /> Depth Filler Matgrial & Depth <br /> i per <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTIONavailable septic <br /> system feeti1ied if public sewer is <br /> 'Installation will serve: Residence Commercial_ Other # <br /> Number o rvi Number of bedrooms j r table depth <br /> [ Compartments No. <br /> :Character of soil to a depth o ' <br /> I <br /> SEPTIC TANK. ❑ -Type/Mfg Capacity 1 <br /> PKG: <br />