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ADPL I CATI�f�I 'OR PERId I T' <br /> x, <br /> SAN JOAQi3IN COItJbTTY PbBL1C HEALTH S81tvICES <br /> ENVIRONM tAtA'LT$ DIVISION ' <br /> n 1601 Ts RAZELTON AVE`. , PHONE (209)468-3420 r1 <br /> P O BOX 2009 STOCKTON, CA 95201 <br /> 1c RE$ Y R R Y <br /> ( omPlete in Triplicate) { <br /> Applicetion ii here y 1 <br /> application is oasdebin�cc4'liance vithuBan loequinunty �Couttr i ty dinance go. 549and/or <br /> 1862sand thethe <br /> Rules andeidn <br /> Aet;ulgtionedof Shie <br /> Joaqui- County Public Health Servicea.. <br /> S ; <br /> Job Address -'�' ey <br /> City Lot Site/Acreage <br /> v cOwner's Name <br /> Address <br /> 4-V' w. Phone <br /> ti <br /> Contractor_ + � .r r. <br /> Address License No: +n#, phon <br /> TYPE OF WELUI-Ijm?:. <br /> NEW:W <br /> ELL D <br /> s <br /> . �.• .WELL RE, LACEMEIV• [� . <br /> 41, 1 <br /> Y - DESTRUCTION [1 Out oP Service Well'"ID <br /> ti <br /> PUMP INSTALLATION C}J i SYSYEM AePA#1 L7 OTHER`7 Ploiiitdrii� V61f' <br /> DISTANCE T;t NEAREST: SEPTIC tANK s. 11 <br /> �. SEWER LINES - .+__ OISP05ALi.f). PROP. LINE <br /> FOUNDATION A <br /> " GR€CULTURE WELL y OTHE 1+�ELL� . _ P1�3/SUMPS r <br /> itVTENDED U E 'c TYPE`OF WELL PROBLEM AREA CONSTRUCfloN F IyECIFiCATIONS <br /> 0-industrial' b Ope�t Bottom `� ( <br /> D Maniacs Dia of Well Ezi ovation,� i <br /> C.1•Dafnest€c/Private Cl Grave€ Pack ❑ Ttac '`�--�------ Dia. of Mill Casing <br /> t y `' Type of Casing-, s peciPcAtiona <br /> 1'I Rribiic' !'1 Other 9 S <br /> [71 Delta Depth of Grout She€ .1 <br /> I Eflrrifle€ion _, <br /> Approx. De Type of Grout <br /> — pth i I Eistain E $u"ici Seiiil !nst�led by <br /> ir'1f4/ rk D <br /> t o one 'L]' Type of Pumpi• <br /> H.P. <br /> traction + I # State Work Dtrne <br /> �• Well piaimetef I Sealing,Ffatarfif g Depth <br /> + Depth . Filler MtitEribl �4 t5eptls <br /> TY a <br /> SEPTIC WORK; NEW INSTALLATION AEPAIRJADOITION I I DESTRUCTION l,I�INo septic system permitted it public sewer lis <br /> ' .:- <br /> Inl n will"I've: f;eaideHc+3 ;,' vallable within 200 teat.? 19-), <br /> Commeft:isl t7thet T' } <br /> Num livir urf6ts: �'? ^' r <br /> Numblti of IsedPoo <br /> Charac�f bfOrto b depth 3 iddt <br /> 4 � I <br /> t ^ � # <br /> SEPTIC T4f" - , <br /> atei Cathie depth4PI, <br /> PKG. TREA No: <br /> Compalrtmente �J f <br /> h ` Method of Disposal <br /> r Distance td rtilarest: Well Fbunclatinh ®� ' <br /> Property Line R � <br /> LEACHING LINE it <br /> ` <br /> , ;No. & Lendth�O' lines - <br /> FiLTER BED, C) 618-tante to he-stai': Well Q r �IenBih/size <br /> kaunddtiori Property I Ina ' <br /> SEEPAGE _ <br /> PIT5 I I Depth I $irei <br /> SUMPS �I Distance to nearest: umber <br /> DISPOSAL PONDS p Well ,, 'Fotindatip6. Property Line --tom--- i <br /> I hereby certify that 1 have ptepared this application anti that the work will be don Iff aLcordance 4irith San Joaquin county ordingnces, state laws, and <br /> rules and regui8tioha o} the San JoAcluin OdUrity ! <br /> Home owner or I€n nabd agent's 6ignature cert!liea the f6ilowing 'I tiestify that�h tfti8 performance of the work for which this permit is issued; I shag not # <br /> employ any person in loch stunner ata to b9ioi4iit stibl+3ct to warkman`t eompeni ti es of California." Contractor's hiring or sub-canfractii g signature <br /> L' <br /> certifies the follow€h1 "I Certify Chef in the Pdrforrftence of the work for which this l�erinit Id iof Cal I aheH employ orlonPerios hiring <br /> to workman'!tom nater <br /> tion laws of Caltlorftla." i <br /> ensa- <br /> The applicant m all for fired ' s <br /> pectloria. Complete drawing on reverie side, <br /> Signed X <br /> Title: . //�L/ <br /> Date: <br /> FOR DEPARTMIr€ l'USE ONLY <br /> Application Acceptad by � <br /> " Date ' '' Area i <br /> Pi or Grout inspection by �, <br /> ate .r ;Final InsPection by <br /> Additional Comments: Date <br /> Applicant - Return All copies to: •8811 Joaquin County Public Health `° �* <br /> i• <br /> Services, Environmental Realth Pe6it/Servicee <br /> + <br /> 1601 E. Hatelton' Ave.; P C Boit 2009, Stockton,.CA 95201 <br /> FEE . <br /> INFO AMOUNT DUE AMOUNT REMITTED CR13 " i <br /> CA$Hs . RECEIVED 9Y DATE PERMIT'NO. <br /> I H 74 7t I R EY.,i e y,- �� <br />