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41--S C..5455 F G1=. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC ftEALTII 13URVICliu <br /> ENVIISO.tvr. ,NTAI. IirALTIi DIVISION <br /> P U BOX 2009, ST(YCKTON, CA 95201 <br /> (209) 488'-S4Aq <br /> -� ❑F.R�IT gXpi1�;,•^+ 1 YF`AFi 'F'ftnb PA3'� IS3UI3� <br /> (COMPletc in Tripl. c te) <br /> ArjllcatiaD S■ herety YeCC•to .ten JooRrrib County for a perut, to conszlI end/or install the verlc hereir, deaerltad. This <br /> eyplIeatiod ie rade !n cod 1141 vith sap Joaquin county Ordinance No. 544 and 1062 and the Faleo and hegulatleaa of San <br /> Joaquia County Public lie+lth Sery eat. y��,� Z <br /> �. — City ��-t-- Lot 31ee/Acree�a �'� l�k <br /> Joo Address ir��e <br /> ")/y, t <br /> y(3 C A Add,eas e"LJiSy � Phone <br /> gwnir'e Nemo <br /> Add less" a_k]e�o�.IC 1r' °Licens^ ke. a hang <br /> ConNattor °f <br /> TYPE OF WELL/PUMP. NEW yh'ELL V1ELL REPLACENIENT t DE TRitTlON w�]t tc-gnl.wrl" well �7 <br /> PUMP INSTALLATION G SYSTEM REPAIR C 1�(LL�^i, Irrl/►I�'` <br /> SEWER LINES -- DISPOSAL FLU. -PROP LINE <br /> DI ISTANCE TO NEARI SEPTIC TANK «---� AGRICULTURE WELL OTHER L7ELL PITS!SUMPS <br /> FOUNDATIO-' ^—�— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> Die,of Well Casing Vr <br /> C.l Industrial ❑Open Bottom u M+ntect Die oI WeII Eatavauon Spec ihcalions <br /> C3 Tracy Typo 01 Geeing 7 - <br /> tl DomesticOnvals 0 Gravel Pact ti Type el Grout <br /> G S'1 Othnr Q Delta Oepsh of Grout Seal ¢ ` <br /> ;r P4IbIIC S.rface Seal Installed by <br /> �!IUIUadpn APRidx, Depth ❑ Eastern \ <br /> Type of Pump �-- H P -�� -- <br /> State Work Dona_ <br /> Repair Work Done 1] <br /> Well Destruction Cl Well Diarneter Seallr+g Iiatar"l i CepthFiller ileterSal L Depth \ <br /> Depth - <br /> TYPE OF SEPT4C WORK: NEW <br /> INSTAL Z, <br /> REPRtRlADDs710N I DE5TRUGTION Zi `a I�hRr'wdhin 790 feet1-111 Iled II pI'gllc ir�r s <br /> /InitalliII WIII servo: Resitlenca _ Commert4l Othet Q <br /> Number of living unite Number of bedrooms Writer loblo depth <br /> Charector of aorl to a depth of 3 feet:_- — — rro. Coerp+nrnenti <br /> ❑ Type%N•fg Ci Pac�tY <br /> SEPTIC TANK Method of Disposal <br /> PKG.TREATMENT PLT.Cl Pru ony Line <br /> ' Dittenee to easiest: Well �� P 1, <br /> Totol lenglhleise t <br /> EACHING LINE C1 No.6 LCI Of lines Prcpany tine <br /> FILTER BED ,I Distance Io nearest: Well fu ndauan <br /> S fiumhar <br /> SEEPAGE PITS I I Depth ,.�.�—� re Property Line <br /> /$LIMPS L1 Distance to nosrrist- Well Foundalwn — <br /> V DISPOSAL PONDS <br /> I hereby eartify that l have PreAU M1 inti opPiici UOn and that the wprk will bb aon0 In accarPanCO with San Joaquin COvnIY ar01010ce3,stale IBWS,and <br /> rules and ragular,ons of the Sin JDequln County <br /> Mg <br /> s itsued,I shall not <br /> Kom owner or licensed agent's Cjnature seri'!es the 1pllow n "I candy'"at in Ina'1 componriallo..)Earlo4rirf calR Ol tris work for <br /> which the r$Lit- ignatvrt <br /> Employ rho person <br /> in much nut teat into Wcom Perform <br /> lion <br /> of subject o Wulkif,tin III wok for Which 1h,p,m t oissued,Oihatt ernPIOYePaoaJn'Itu9;Crl to wwOOfkrnf t!s CGmpins4 <br /> lion levy$of Catiforrr..." r a/ /J <br /> e applica ust GI alt recurred fnspeciions. Complete diexrng On ever ,do. L�' L <br /> Date <br /> Title: <br /> FO DEPARTMENT E ONLY <br /> Date r Arse <br /> Application Accigled byDateFinal Inspot n by Date <br /> pit or afoul IAapection II <br /> .�-�--- <br /> Addltlonal Comments. <br /> ApFlletnt ^ TH SERVIC" <br /> Return all copies to; SAVIRONid&NTALUIs O EALTNUNTY UDIVIGIONLpERHITISERVICC3 <br /> ENV „ 5nH JOAOUIH, p O boa 2009, STOCKTON. CA 0201 <br /> FEE AMOUNT DUES AMOUNT REMITTED `ASN <br /> rzfCEIVED III DATE PEpMIT NA. <br /> . <br /> It,5i7�IREV.NRaI <br /> ru•.ase -•- f <br />