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• APPLICATION -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENPIRON100TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)408-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete i, ' <br /> M Application Sshereby made,to Ess Joaquin County for a Pewit to construct and/or Install the wort. herein d...ribrad. This <br /> application Ss .de to caaPllance with Ban Joaquin County OrdlnAbce He. 549 All 1862 sed the Rules And RaNLtione of Sea <br /> Joaquin County PublicHealthServ-cna. <br /> Joh Addren / I I Q/ I4/^N �f ' _ Cr r'�/�v�E�N[b��t/�,Sl to/Aerease <br /> / /= Addrev (J� / / !YQ/ 111 Phone <br /> OwMr'a Name q./��� <br /> Convactor (/ W /-e� AdER53 L1:clsen0. Pher's <br /> 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Mepstoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISFOSAL FLD._ PROP. LINE �_ I <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS •-�' <br /> I <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS M1r <br /> ❑ !nu <br /> durnl ❑Open Bonom ❑ Maniac. Dia. of We"Excavation Da. of Well Cae✓q <br /> EI O,wwk tier Private ❑ Goval Pack ❑ Tucv Type of Caein9_ Swdicalfota <br /> "I Public I1 Othal El Delta Depth al Grout Seal TYpe M Grout 'I <br /> I I I Irrgalan _Aplroe. Depth I I Eastern Surface SNI Invalbd by r\ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> well NatmClq ❑ WAR Diameter Beellly material L Depth <br /> Depth Filler Material a Depth V <br /> TYPE OF SEPTIC"WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I INo Nptle tyfam permmed it PIING Nwas we <br /> avlllable within 200 1NL1 <br /> Installation willNM: Rep arta� Coinn ial_—Other <br /> Number of living units: N.thes & droc a /L <br /> chat.,.of soil to a depth of 7 1N0 YL L�o� —Water bW' eipth <br /> SEPTIC TANK ❑ Typo/Mlg Capacity— No.Campanmema <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> I Distance to lull Well Foundation Pune,Line / <br /> LEACHING LINE No.B Lengthof linea T^t11 le^gth/she <br /> FILTER BED ❑ Distance to nwre a: Well 71on Foundnron�� Property Lim <br /> SEEP <br /> Pill SI''Ii�Orapth Site Nµmber <br /> 5 MP dDi\unce m nNiNL WNI Ur Fourusnon�7 Propory,Lina 7-b <br /> S O P <br /> SAL ONO ❑ <br /> I retire,y LPDS I hew Drepaled Iii\application and that IM work will be done in ectoroan<e with San Joaquin[aunty ordinances.erste aws,arW <br /> rule.and ragulatans of the San Joaquin County <br /> 3 m <br /> Hoe owner or licensed agent signature cardea the foaowrng:"I eerily that in the Performance of the work few which this perms to issued.I NAR net <br /> ampH any parqu in such Nn.,as I.mcOrM--bNct 10 w0lkman'I cgmPenNlin(`.awe Of California/ Contractors hiring of WDCONIett irlg signature 6 <br /> c,i"the Iclewing:"I certify that in row parformanca of the work for which Ihls Permit n issued.I shall ramploV Persona subtract to workman i cempenN <br /> tan awn o'Ceiforthu <br /> The spook t R fop� • outs impaction. Complete d-ra1wing_rn rover ids <br /> 3 Sgn.d Kar Date: <br /> �� F q DEPARTMENT USE ONLY <br /> Application Accepted by Pats -� 6a <br /> Pit or Grout Inspection by Dau Final Impaction Dy Uat✓� <br /> AddrbMl Commence: y <br /> Applicant - Return all cOpien to: San Joaquin County Public Health service. l!E <br /> Environmental Health Permit/Services <br /> S 445 NHS N San Joaquin, P 0 Box 2009, Stkn, CA 95201 (/ <br /> FEE AMOUNT DVE I AMOUNT REMITTED CASH BY DATE PERMII'N0. j <br /> K / <br /> INFO CASH R <br /> til H.e <br />