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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIIENTAL HEALTH DIVISION ' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ; <br /> PERIdIT F,%PIRES 1 YAR FROM <br /> DAT -, S , <br /> (Complete in Triplicate) <br /> the work herein described. <br /> Application is hereby made to San Joaquin county for a permit to construct and/or install s <br /> long of San <br /> application is made in cea�liance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regula ; <br /> Josquin County Public Health Services. <br /> � City Lot Size/Acreage <br /> Job Address ' <br /> Owner's Name <br /> Address Phone <br /> ri �—A-duress". _�0'�-- y- - - q-2 <br /> /'vLicel se Not �Phone� �, 07 <br /> Contractor DESTRUCTION Out of Service Well ❑ <br /> NEW WELL ❑ WELL REPLACEMENT Monitoring Well ❑ <br /> (TYPE OF WELL/PUMP: OTHER 0 <br /> PUMP INSTALLATIONSYSTEM REPAIR <br /> i , El <br /> LINES �---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: <br />' FOUNDATION =- AGRICULTURE WELL OTHER WELL_ PITSISUMPS� <br /> SEPTIC TANK <br />' INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFI I NS Dia. of Well Casing <br /> C7 Industrial V Open Bottom D Manteca Die. of Well Excavation 1 Specifications <br /> omasticlPrivate ❑ Gravel Pack L7 Tracy Type of Casing ,GAB <br /> `{! Delta' 'Depth of Grout Seal 1QD pe-of out <br /> I l PublicI 1'Other �- . <br /> j I Irrigation Apprax. Death l ] Eastern Surface Seal Ins[ailed by — <br /> of Pump H. to Work D <br /> r Repair Work Done U Type Sealing Naterial i Depth <br /> Well Destruction Wall Diameter O (�t� <br /> _Depth_. -- LIOer Material i Depth yv` <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION 1 1 aNBils��tivvshm240 1�;fed it public sewer is <br /> Instillation will serve: ,Residence Commercial— Other �- <br /> Number of living units:- Number of bedrooms <br /> Water table depth � <br /> Character of soil fe <br /> to a deptll 3 st:= ' <br /> ` SEPTIC TANK 0 Type/Mfg- Capacity No. Compartments <br /> [ ll TREATMENT PLT.❑ -- � Method of Disposal <br /> �. " " ' Property Line <br /> Distance to nearest: Wa41 Foundation <br /> a s r <br /> Total length/size <br /> LEACHING LINE ❑ No. A Length of lines , <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> I _ <br /> SEEPAGE PITS 11 Depth Size Number <br /> f SUMPS L1 . Distince to nearest: Well Foundation Property Line } <br /> i- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> rules and regulations of the San Joaquin County <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, k shall not <br /> { employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- e <br /> r The applicant must tail for elf requirgo ' spe.ctmns. Complete drawing on reverse side. <br /> ' Title: - Date: AV-Yla— <br /> OR <br /> -D ARTMENT USE ONLY <br /> Area <br /> Application Accepted by - Dats <br /> =_ <br /> Pit or inspection by <br /> Date �!� inel Inspection by Dae <br /> Gr t <br /> Additional Comments: <br /> Applicant -Return all copies-to: San Joaquin County-Public Health Services <br /> Environmental Health Permit/Services J� <br /> 445 N San Joaquin, p O Hoz 2009, Stil CA 95201 <br /> i <br /> FEE CK RECEIVED BY DATE PERMI7�NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> n/ S,r, <br /> . FO <br /> EH 13.24 Ill All <br /> fS t4.20 I <br />