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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N o "k) <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES ] YE FROM D TE SU ' <br /> (Complete in Triplicate) <br /> I <br /> tall <br /> Application is hereby made <br /> compliemce JoaquincountyJoaquin Counr a ty Ordirmit tnancenstruct No. 549�ando1862aand thee work Rules andeRegulationsdof Sana <br /> application is made is cotes <br /> Joaquin County Public Health. Services. (t t� <br /> Job Address <br /> a City Lot Size/Acreage <br /> XOwner's <br /> AddressPhone <br /> Name v Address License=No. Phone <br /> Contactor <br /> PE OF WELL/PUMP: NEW WELL ❑ WELD REPLACEMENT C7 DESTRUCTION ❑ Dut of Service Well ❑ <br /> pTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑� �� _- -- ` 'SYSTEM REPAIR ❑' , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS _..,� � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> F] Oomestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_. Tyles of Grout r � <br /> I'I Public Cl Other n Delta Depth of Grout Seal V '' <br /> I I irrigation w Approx. Depth I I Eastern Surface Seal lnstaliiid-by <br /> Repair Work Done U Type of Pump H.P. <br /> Stats Work Done _ <br /> Well Destruction O Well Diameter Sealing Material.& Depth ' <br /> Depth filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiON I I DESTRUCTION alvailablerw thin 200 festsystemt`ed ii public sewer is <br /> Installation will serve: ilesidsrice:-Commercial� Ocher <br />` Number of living units: Number of bedrooms <br /> i Character of soil to a dapth of 3 feet: � Water table depth <br /> SEPTIC TANK Type/Mfg Capacity - No. Compartments <br /> ?� Method of Disposal • w <br /> PKG. TREATMENT PLT. ❑ } ' <br /> Distance to nearest: Well Foundation �- Property Line 1� <br /> 1 Total length/size <br /> LEACHING LINE ❑ ^No. ✓f, Length of linea <br /> kl FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number Y <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> work will be done'in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the <br /> rules and regulations of the San Joaquin County `�- <br /> Home owner or licensed agent's signature osrtif4s the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature <br /> certifies the following:,'I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's <br /> compensa-tion laws of California." ; _ <br /> The applicant mut all for all required in�pecY ns. Complete`drawing on reverse side. <br /> / eros Vile: Date: _ — <br /> IJ'�' OR DEPARTMENT USE ONLY <br /> Application Accepted by Date '2 Area Z" <br /> Ph or Grout Inspection by Date Final Inspection by pats S <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 /> I FEE AMOUNT DUE AMOUNT REMITTED CASH KV RECEIVED BY DATE J PERMI7-NO. <br /> INFO <br /> JR <br /> . EK ty21(REV.i i R of <br /> £H 5426 L <br /> k <br />