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a d <br /> r APPLICATI.09 FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �� , <br /> 468-3 <br /> 445 N SAN JOAQUINSTOCgTON(2CA,95201420 SCANN <br /> P O BOX 2009, <br /> pERM T ggpIRFS 1 FROM D ATE LaaM <br /> (Complete in Triplicate) <br /> for s. tall <br /> vort <br /> in described. <br /> Application is hereby made tom Joaquin CountyCounty Ordirmit tttancenNo 5k9struct sandol i2sand <br /> application is made in comp theeRules andeAegulations of Sans <br /> Joaquin Count Public Health Services. <br /> Cit Lot Size/Acreage <br /> 9I j <br /> Job Address <br /> Phone4 <br /> !i &dress <br /> Owner' Name Qr <br /> ' en5e No. G► In <br /> r <br /> On t3Cftn WELL REPLACEMENT DESTRUCTION ❑ t of Service Well Q <br /> NEW WELL ❑ OTHER ❑ Monitoring well <br /> TYPE Of WELLIPUMP: SYSTEM REPAIR <br /> PUMP INSTALLATIO DISPOSAL FLD. PROP. LINE <br /> SEWER LINES �� MPS `f <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL � PITS/SU <br /> FOUNDATION �—-- ' <br /> I INTENDED USE PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> TYDia. of Well Casing <br /> 4 Dia. of Well Excavation <br />{ C7 Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> I C] Tracy Type of Casing_ j <br /> sticlPrivate ❑ Gravel Pack Type of G ut <br /> Cl Delta Depth of Grout Seal <br /> I Public Cl Other <br /> r Approx. e 1 I tarn Surface Soul Installed by <br /> I I I Irrigation State Work D <br /> of Pump H.P.Repair Work Done ❑ Type Sealing Ifaterial i Depth <br /> f Well Destruction ❑ Wall!Diartle MuQr Material & Depth <br /> I Depth / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADOITION I 1 DESTRUCTION I I availablerwithin 200 lost.) if public sewer is <br /> .II <br /> Installation will serve: Residence-- Commercial Other <br /> 'i, Number of bedrooms <br /> Number of living units: r �3 <br /> y Water table-depth <br /> Character of sob to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg *� 1,Method of Oispasai� t <br /> PKG. TREATMENT PLT.O I� res <br /> pistance to neat: Well Foundation' ' Property Line <br /> tr <br /> N ; <br /> i 'Total length/size <br /> LEACHING LINE ❑ No. f1 Length of lines �rt Line (� <br /> f FILTER BED C7 Distance to nearest: Well Foundation ? pro C <br /> SEEPAGE PITS 11 Depth Size . „, s t �� <br /> Foundation Property_Line <br /> SUMPS CI Distance to nearest: Well .1 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with S Joaquincounty ardtate laws, and <br /> f ruli.�s-and regulations of.the Sen Joaquin_County`+„•,_- T.�_-�__ --- - --� <br /> Ho owner or licertang signature <br /> --Wigape's signature oertifies the fOliowmg: "I certify that In the performance of the work for which this permit is issued, 1 shall not <br /> I <br /> certifies mthe f sso�nn such annest n the Performance Of the workman <br /> kmaork oswh c this teen laws of Cesdliloshall emploCony parsonstsubjecring t to worktman!s ampensa <br /> g� <br /> tion laws of CAG <br /> rnla.' e <br /> The appiic t m st call for al !red i coons. Complete drawl g on arse side. Q �" <br /> I <br /> Ti <br /> Date: <br /> Sig J <br /> P' FOR DEPARTMENT USE ONLY <br /> r JDate Area <br /> Application Accepted by <br /> ii Final Inspection by Date <br /> Pit or Grout Inspection by Data -- <br /> Additional Comments: I� <br /> I Applicant - Return[ftll copies to: San Joaquin County Public Health Services <br /> f Environmental Health Permit/Services <br /> P. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT <br /> RECEIVED BY D TIE PERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> ♦ EN t]•2�tr1EY,r/h 5i <br /> EH 14.10 <br /> 1 , <br />