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t <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMEj,1T HEALTH DIVISION <br /> 445N SAN JOAQUIN' PHONE (209)46$-3420 PAY E4`4T <br /> P O BOX 2009; STOCKTON; CA 95201 RECERm-n <br /> PEIT . !REMAR FROND TE Q C� 2 1 Inij <br /> {Complete in Triplicate U t,`;���� �OAt)IMNCOLINTY <br /> Application is hereby yelde to Sinn Joaquin County fora t' IIEAI•�ff�FRVICFS <br /> application is mads in c permit to construct and/or Snatall the <br /> Joaquin <br /> This <br /> r' <br /> °a4 h Sery frith Baa Joaquin County ordinance No. and 2 62 and the Rules had lie' <br />� J uin Cotmty Public Health Services: 5 9 g <br /> G- gulations of San <br /> Job Address �7 <br /> City&�o_ Lot Size/Acreage <br /> Owner's Name � q <br /> Address <br /> CPhone .J�`► ' {pc� <br /> ontractor a�n� Ch �(� <br /> TYPE OF WELL/PUMP: Address <br /> NEW WELL 0 License No,�/� Phone 7 -Q ei <br /> PUMP INSTALU-tloN 0 LL EPLACEMENT fl DESTRUCTION Ll out of Service Ve.I <br /> ISTANCE l Cl <br /> DTO NEAREST: SEPTIC TANKSYSTEM REPAIR IR- OTHER 0 Monitori til <br /> ----� SEWEA LINES ng ell <br /> FOUNDATION DISPOSAL FLD. PROP. LINE <br /> INTENDED USE TYPE OF WELL PROBLEM OTHER WELL,;_ PITS/SUMPS <br /> I -- AGRICULTURE WELL AREA <br /> Cl industrial -----^ CONS TRUCTION SPECIFICATIONS <br /> O Open 8attom C7 flAanteca Dis, of Well Excavatiotf 9 <br /> i�Domestic/Private 0 Gravel Pack Dia. of well Casing <br /> I'I Public 0 Tracy Type of Casing_ <br /> fa Other n Delta Specifications <br /> I I Irrigation Depth of Grout Seal <br /> -- Approx.umDepth I ! Eastern 5 dace Seal installed by Type of Grout <br /> Repair Work Done 1I�, ,y, � y � <br /> L17 TYPE of Pump -=--�•�•••-��. H.P. t' /� <br /> Well Destruction p Well Diame"ter ms Seallhg $6teriiil a bepth Stats Work Donee�Ci'1`>d [►f <br /> Depthfn,sC4t1 SQnr it7rV~ IIbSF' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPA pi ADDIONllei r1111 e Depth / 1 <br /> DESTRUCTfON 1 i INo septic system permitted if public se <br /> Intta will serve: Residence available within_ 20o feet.l _ <br /> Commercial Other <br /> Number of livrn s; Nurnber of bedrooms <br /> Character of soil to a dapI taste <br /> SEPTIC TANK O Type/M g I Water table depth <br /> PKG. TREATMENT PLT. 0 � Cap No. Gompartmente <br /> Distance to nearest; weil Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE Cl No, g Length ea <br /> FILTER BED CI Distan o nearest: Total length/alto <br /> Well Foundation �`- <br /> erty Line <br /> SEEPAGE PITS I I Depth <br /> SUMPS Sr78 Number <br /> L1 l Distance to heerest: Well <br /> DIS P L PONOS p Foundation " PI•oparty Line <br /> I hereby certify that I have prepared this ipplicailoA and that the work will be done in accordance with San Joaquin county o►dinr;nces, state fawn, and <br /> rules and regulations of the San Joaquin County , <br /> Home owner or licensed agtint'i sign9;urs certifies the folfowin ? <br /> employ any person in ouch manner ae to become subject`io workman's ctompensetion fhe aewaoo}Cahlorniah�Cont actor Work for Which <br /> ftuiiigipr iub-eonssue , signature a <br />° certifies the following: permit y issued, I shelf not <br /> "f certify that in the petlormance of the work ftSr which this <br /> tion laws of California." permit is issued, I shoji employ pefsona iubjecf to workman's cam <br /> The applies utas calf for I required ins ions. Complete drawing n reverse side. pens+• <br /> Signed X <br /> i <br /> Title: <br /> Data: <br /> FOR DE ENT USE ONLY <br /> Applicatlon Accepted by �, p+ <br /> Date Area. D <br /> Pit or Grout Inspection by 4 <br /> Date Final Inspection by <br /> Additional Comments: Deis/ - <br /> Applicant - Retdrd all copies to: <br /> San Joaquin County 01i <br /> Environic Heaith Servicet; <br /> Environmental $@alto l3ermit/Servicci, <br /> 445 N Ban .Joaquin; P U 130z 2009; Stgnj CA 95201 <br /> FEE AMOUNT DUE � <br /> INFO AMOUNT REMITTED C y <br /> '` I RECEIVED BY DATE PERMIT'NO, <br />