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APPLICATION FOR PSE [I T <br /> SAN JOAQUIN COUNTY PUBLIC j� .3 3 <br /> ENVIRONMENTAL HEALTH ..,�. <br /> 445 N SAN JOAQUIN, PHONE ( —3420 <br /> P 0 BOX 2009, STOCKTON, <br /> is RES 1 <br /> (Complete in Trap1I <br /> AiMlication is bareW etw4e t0 Sam Joaquin County for a permit to construct %N.— s <br /> application is vs4e in compliance vi" Baa Joaquin county Ordinance Iso 5L <br /> Joaquin Ovulotty,.�Publle Healtt Services r r� <br /> Job Andreas s! �' City '24LA4t4— Los. Size/Acrca,gc <br /> Owners Nan+ac:kevcU-9 A Pb-" C-,Address 10 � �0 SYS-P69S` <br /> �Scs�a69�fion ° �1-- <br /> Contratto►Sat�S �t�r c.4 `�Fddrtss ?� "�' 93 t �'Ltt:enst I�lo <br /> TYPE OF WELLIPUMP NEW WELL WELL REPLACEMENT n DESTRUCTION p Out of Service Me11 ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O >ffonitorina Yell ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrral C Open Bottom D Manteca Dia of Waft Excfivauon Dia of Well Casing <br /> ,'Kbomestie rrvat ❑ Gravel Pack ❑ Tracy Typo of Cawnp SOL sin F V L Specifications _ <br /> I I Pliblic 'btnr►/1fo+c�r�a�i n Delta Depth of Grout Seal ,/S Ty" of Grout u Ee�..`•"l <br /> I I Irr.gatuon A rfMpproa Depth I I Eastern Surface Sairt installad by Sw/5 Err �o °•'� V: <br /> Repair Work Done 0 Type of Pump HP State Work Done arl11 <br /> Waif Destrur.14it ❑ Wolf Diameter 420, Seal-ing lirterial a Depth Ao%''n 7-c-in RNs I w.-Zo"- <br /> Depth ri ller Msterisl i Drpth S►.1 ���;� <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION t I {No tap lcL,1""m porrrutied d public Hewer is <br /> k vlrif!'iln 2W Iasi } <br /> ic r. <br /> }netallatiOn w}it*en* Rftdenoe.____ Cornrrercial_ Other u ta-i+l R[, g <br /> Nur*+larr of Wong vntis Number of badrooryls t::�t✓ a �^b-- <br /> Chsrbcter of *oi to ar V rr• <br /> 6apth of 3 fart � *• VJ�ta^^ �Cpih W <br /> SEPTIC TANK ❑ Type/Mfg capacity SP,N � �� a to � <br /> PKG TREATMENT PLT ❑ wt �i 1C � <br /> i''p� <br /> Danoe to nearest �Watl Foundetwn PL `r } L (� <br /> LEACHING LINE C) No b Length of toast Total length/size <br /> FILTER BED ❑ D_stancs to rwrest. well <br /> i r <br /> SEEPAGE PITS I I Depen Erse <br /> Post-It"brand fax transmittal memo 7671 �or pages . <br /> � <br /> SUTo�� n F �SUMPSLf Drturrce to nearest wall L�►eV�.�,,. <br /> fllsPasAL Perlas o <br /> rulleseby annd rreig elatrcm ohat I f the pS�on J a ourna c..mtyen ares that <br /> Hosie owryr or 111coraa'd agent F*.pneiura con4es the 101101w Fax fQ Fax s r I t shalt"I <br /> 01`1`010Y any prtaon in s+,+ah nvNvw as to become aubtect to w I ! 3� -� r f] j �JC�t In` r r 3 4 a.pnotwe <br /> er.•ellres the foaow,r,p Ice"that in the pertormanee of lhr eonNownas <br /> con laws of Cataorrila <br /> The applicant t uI for alt reQuired +nspectrons Complete drawtny on reverse silo <br /> SrOned Tito -=�IgJS a Date / �C <br /> 7�I/7 FOR DEPARTMENT USE ONLY l <br /> Appircation Accaplen by �( Date f Z13 Ara* OZIgZ fI.L- <br /> Rif or Grout In ijubcL on bt Data S / Final Inapectron by Date <br /> Wltxxwl Cornmonta <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> tbviroamental HealtA Permit/Services <br /> 445 N Sart JOLQUiM, P 0 Box 2009, Stkn, CA 95201 <br /> 3!J�f INFIp AldOuNT Out AMOVIVY REMITTED GASP+ RECEIVED BY DATE PERMIT NO <br />£� t} inn. ,,.Fr �q ee ��r-y 11,46q8t 11 30 q36DI&-23 <br />