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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-5420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YE R FROM A E <br /> (Complete in Triplicate) <br /> work her <br /> in describe . <br /> Application Is hereby �e.liance xithuhu9anqin SanCJoaquinoCountyrOrdinaacenNo. 549aando1862sand thee <br /> eRules andeRegulationsdof Sans <br /> application is madein comp <br /> Joaquin County Public Health Services. / <br /> a City [Lot Size/Acreage <br /> Job Addrass r d <br /> ddress one. I <br /> Owner's Name. <br /> a�•' <br /> icense No. <br /> Phone <br /> Contractor <br /> ddress <br /> TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �+t of Service Well_Gl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well [3 <br /> I DISPOSAL FLD PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PITS/SUMPS <br /> t FOUNDATION ;AGRICULTURE WELL `�"" OTHER WELL <br /> } �r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / Dia. of Well Casing v <br /> n Industrial F ❑ Open Bottom ❑ Manteca Die. of Welt Excavation <br /> Type of Casing (Specifications ! <br /> F I Domestic I Private Gravel Pack ❑ Tracy / Type of Grout <br /> I'i Public �#1jO Cher f-1 Delta Depth of Grout Seal / <br /> irrigation ° GCLG Approx. Dept I Eastern S mace Seat Installed by <br /> Repair Work Done 0 Type of Pump - H•P• State Work Done <br /> Well Destruction Sealing Material 6 Depth❑ Well Diameter —T--- Filler Material g Depth <br /> • Depth,.� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1-REPAIRiADDITION-I'1-'DESTRUCTION l I anvailabletwi hine200 feetrl�ed if public sewer'is <br /> Installation will serve: Residence Commercial , ' Other # f� a <br /> Number of living units: *Number of bedrooms _ ._71 � <br /> Water table depth <br /> Character of soil to a depth of.3 feel": , <br /> " Capacity No. Compartments <br /> SEPTIC TANK ❑.Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Method of Disposal - <br /> f Distance to nearest: Well Foundation Property Lilye— <br /> LEACHING LINE ,. j_} No. 8 Length of lines Total length/size <br /> FILTER BED : ❑ Distance to nearest: Well Foundation Property Line <br /> e <br /> SEEPAGE PITSA`=* I I Depth' ' "" "Size Number <br /> f <br /> SUMPS. `w Distance to nearest: Wel Foundation Property Line <br /> iDISI?OSAL PONDS 0r <br /> I hereby certify that I have prepared this application and that th}e work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> ance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perform <br /> t <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signatur <br /> .certifies the following: ,'I certify that in he performance-of.the-work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> FThe applicant quire ' s s:Complete drawing on (ever ,Side. <br /> Date: <br /> Signed ,. <br /> .-t F p�OlVLY l <br /> l Application Accepted by <br /> Data Area <br /> E `5. O Final Inspection by Date a' <br /> ffff Pit r rq out Ins, coon by 11 Date <br /> I Additional Comments: <br /> t <br /> Applicant - r Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> ¢ 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K$H RECEIVED BY HATE PERMIT N0. <br /> INFO <br /> �- <br /> i 7 � ¢ <br /> a TU <br /> EK 13-21 tREY.t/e 5l r { (� 3 l �� "� <br /> EH 5426 <br />