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'F APPLICATION FOR PERMIT. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ; <br /> 445 N SAN JOAQIIIN, PHONE (209)468-3420 f <br /> R P O BOX 2009, STOCKTON, CA 95201 <br /> pERM T EXPIRES ] Y FR M D TE S <br /> (Complete in Triplicate) <br /> Thi <br /> Application is h�ebintscde toson <br /> nce with 113auCJOaquinounty for <br /> County Ordinanceconstruct <br /> Ro Su9and/or <br /> iB62install <br /> asnd the Rules aadherein <br /> Regulatioasdof San <br /> $. <br /> applies <br /> Joaquin County Public Health Services. <br /> /Acreage <br /> Job Address <br /> , Phone <br /> Address <br /> Owner's Name <br /> ). ! <br /> ] AddressS4 V� ' •icense No. �Phone <br /> Contractor Lt L DESTRUCTION r_1 <br /> Out of Service 1fe11 ❑ <br /> TYPE Of WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT n Monitoring Well U <br /> SYSTEM REPAIR C] OTHER ❑ <br /> PUMP INSTALLATION O � <br />` SEWER LINES �— DISPOSAL FLD. <br /> PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��— <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />` `�` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> .-`iNTENDED USE �— Dia, of Well Casing <br /> '❑ Industrial ❑ Open Bottom Li Manteca , Die. of Well Excavation <br /> Type of Casing Specifications <br /> Fl <br /> C.) Domestic/Private ❑ Gravel Pack 1 Tracy Depth of Grout Seal _ Type of Grout <br /> - I"i Public ["1 Other fDelta . <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Saul Installed by <br /> of Pum H.P. State Work Done _ <br /> Repair Work Done U Type p Sealing Material i Depth <br /> Wail Destruction ❑ Well Diameter Piller Material i Depth (\ <br /> Depth `may\ <br /> TYPE OF SEPTIC WORK. NEW IN5TALLATION I I REPAIRlADDITION l TRUCTION I i aNailablsllw withsystin feet.led'I public sewer is <br /> Installation will serve: Resjdence Commercial Cher <br /> Number of Iivinq units �— Number of bedrooms \ <br /> Water table depth <br /> Character of&ON to a depth of 3 feet: <br /> /Mfg Capacity l� = %No. Compartments <br /> SEPTIC TANK 8---�Ype Method of Disposal <br /> PKG.`TREATMENT PLT.❑ / Property Line <br /> Distance to nearest: Wel Foundation <br /> k <br /> LEACHING LINE ❑ No. m Length of lines <br /> i Totallengthlsize <br /> �-- <br /> FILTER BED ClDistance to nearest: Well_—Foundation Property Line� <br /> Size Number <br /> SEEPAGE PITS Ii Depth =� "'� <br /> l LI Distance to nearest: Well i✓ Foundation Property Line <br /> SUMPS 1 <br /> I]ISPOSAL PONDS ❑ ` <br /> I hereby certify that I have prepared this application and that the work wills done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the.San Joaquin County rr a + - <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 shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of ed,I hi ll Contractor's hiring c sub contracting signature <br /> esrtifies the foNowinq: _'I certify that in the performanceofthe work for which this permit is issued, i shall employ persons subject to workman's compensa <br /> tion laws of Californ <br /> a_s_pplrc at call to all ulr do . C drawing on r side <br /> T le: Date: <br /> D 4MENT USE ONLY <br /> E r _ Date Area <br /> Application Accepted by <br /> G Pit or Grout Inspection by <br /> Date — Final Inspection by Date <br /> I Additional Comments: <br /> F eturn all copies to:Applicant - RSan Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> k 445,H�San_Joaqula.,-P O_Box-2009.,_Stkn,-CA..95201: -.----—�— <br /> f RECEIVED BY DATE PERMIT'NO. <br /> } <br /> JEAMOUNT DUE AMOUNT REMITTED CASH <br /> Z7�EM 13.24 IREY.+/AS <br /> EM 14.21 <br />