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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERi[IT E%PIRES YE FROM DATE ISSM <br /> (Complete in Triplicate) <br /> Thi <br /> Application is hereby mede.to with Ban County. <br /> for <br /> aoaquin permit <br /> OrdinancenNo-5k9ct aandp1862sand the tall eRules and vork eRegulationin sdOf Sans <br /> application is PPublicnHealltlience th Services. <br /> Joaquin County <br /> �C <br /> l"'] City. A1�J Lot Size/Acreage <br /> Job Address / ; <br /> Address PSI �C1 Y' f N Phone 4(a <br /> Owner's Name <br /> i <br /> � <br /> Li <br /> Contractor � Address cense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ � WELL REPLACEMENT C] DESTRUCTION CIDut of Service well <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION SYSTEM REPAIR 0 0 <br /> r + <br /> DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK .�—.� SEWER LINES <br /> ` <br /> FOUNDATION AGRICULTURE WELL OTHEfl WELL PITS/SUMPS'— <br /> INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation i tions a <br /> Cl Domestic!Private ❑ Type of Casing_ Specifications Peck ❑ Tracy Type of Grout <br /> I'1 Public 11 Other fl Delta Depth of Grout Seal <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done U) <br /> Sealing Material B Depth V <br />' Well Destruction ❑ Well Diameter tiller Notarial i Depth ...� <br /> Depth <br /> I{ TYPE OF SEPTIC WORK: NEW INSTALLATION l"1 REPAIRIADDITION I I DESTRUCTION I 1 atvailable within 200 feet. ad if public sewer is <br /> l <br /> Installation will serve: Residence___ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Chsrsctat of goo to a depth of 3 feet: <br /> SEPTIC TANK. ❑" Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.-❑ C1 <br /> i Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> k FILTER BED Cl Distance to nearest:- Well Foundation Property Line <br /> a <br /> �f SEEPAGE PITS I 1 Depth Size __- "_ Number <br /> -SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ { <br /> I hereby certify that I have prepared,thisapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatio+ls of the Sen.Joaquin County _h 4� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> bject to workman's compensation"laws of California." Contractor's hiring or sub-contracting signature <br /> employ any parson in such manner as to become w <br /> certifies the following:."l certify that in the performance of the work for.which;this permit is issued,k shall employ persons subject to workmen's compensa <br /> tion lows of California. <br /> The Ica t m s call for I r i U�qc' lete�r wiu@ on reverse side. f <br /> Signed <br /> Title: Data: . — r ;—� <br /> DEPARTMENT USE ONLY <br /> Date�� 1 'x ren <br /> Application Accepted by f y <br /> Date- Final Inspection by Dat <br /> Pit or Grout Inspection bya/ <br /> Additional Comments: <br /> Applicant- Return all copies to: San Joaquin County Public"Health services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH 7 <br /> . EH 13.24 IREV.1/n 61 't <br /> d �` (� 0� <br /> EH 1448 \ <br />