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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)46$-3420 <br /> :�,, P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT ESPIRES YEAR FR M D,& 1 <br /> ,. (Complete in Triplicate) <br /> i <br /> uin County <br /> Application is hereby rnade,to Sea Joaqfar a permit to construct and/or install the uork herein described. This ! <br /> application is mere in compliance Joaq San Joaquin County Ordinance No. 549 sued 1862 and the Rules and Regula ons of Sanvith f <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage _1 ` <br /> Job Address <br /> 'Phone Owner's Name � <br /> .� ense No Phan <br /> Cornlractor ss Service well 0 <br /> TYPE OF E NEW WELL C3WELL REPLACEMENT n DESTRUCTION ❑ Out Mo <br /> WL PU P: Monitoring well 0 <br /> PUMP INSTALLATION O <br /> SYSTEM REPAIR ❑ OTHER ❑ ' <br /> i <br /> SEWER LINES DISPOSAL FLP. PROP. LINE I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> 0 Industrial 0 Open Bottom Cl Manteca o} Well Excavation <br /> Dia. (� <br /> �.�...�..-.,....-a-...------ .1 _"".".,.,,""." ' Specifications <br /> Cl pomestic/Private ❑ Gravel Pack F C7 Tracy Type of Casing= <br /> Type of Grout <br /> Cl Other Cl Delta Depth of Grout Seal _ L l <br /> FI Public t <br /> I I III lion _-Approx. Depth I I Eastern Surface Seal Installed by t <br /> H P State Work Done <br /> Repair Work Done L3 Type of Pump — Sealing Material 4 Depth { <br /> Well Destruction 0 Well Diameter �— 1P111ar Material i Depth N4 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADOlTION I I DESTRUCTION I I available e w thin 200 feelo septic system .) of public sewer is ` <br /> I ► �) <br /> Installation will serve: Residence 1.. Commercial_ Other <br /> Number of living units: __I_ Number of bedrooms Water table depth <br /> Character of soli to a de�pI feet: - —No:Compartments <br /> SEPTIC TANK. J TW@/Mfg "Capacity <br /> �- 4�� Method ot,Qisppsel C, <br /> PKC. TREATMENT PLT.❑ Pr A Line <br /> ^—^Distance•to-nearest:----*Well oundation � oPe Y <br /> r.. <br /> Q Total length/size <br /> qILTIEi <br /> AC �BED _ <br /> No. 8 Length of lines 1. <br /> ❑ Distance t 'nairet t: Well <br /> Foundation Property Lina <br /> pip <br /> SEEPAGE PITS I I Depth —Size l Number <br /> SUMPS LI Distsnes to nearest: Well�- <br /> Foundation <br /> — Property Line I <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that k have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner or licensed agent's signature certifies tile-following:-"I cartify-that-in-.the.performance,of the work for which-this permit is issued, I 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- <br /> tion laws of California." <br /> The applicant at c or r uir nspections. Co a drawing on reverse side. <br /> Signed <br /> Title: Date' <br /> FOR DEPARTMENT USE ONLY q� 1 <br /> - Dateim�:! <br /> Applicatlon Accepted by Pk or Grout Inspection byDate Final In:pection byDate <br /> Additional Comments: <br /> Applicant - Return all copies to: EnvironmentalJoaquin ounty Public Health vices <br /> Health Permit/ServicesF <br /> 445 N San Joaquin, P 0 Box 2009, Sikn, CA 95201. <br /> FEEAMOUNT DUE AMOUNT REMITTED CK IVED f!Y DATE PERMIT'NO. <br /> {p' INFO CASH <br /> "I 'EH 13-24IIIEV.I195V jig 7r, <br /> F- 3 <br /> ;tom EH 14.2e ._ <br />