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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> nwuusT �xpIRES 1 Y R ���� <br /> (Complete in Triplicate) <br /> Application is hereby made t0 8rut �oa4uin County for a permit to nstruct No 549 ando1662etall nd. theevork Aules andein Regulationsdof Sans <br /> application is made in cotr�liance with San Joaquin County ordinance <br /> Joaquin County Public Health Services. <br /> 361 City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name `�'�w' L Addres � <br /> License No� Phone m <br /> Contractor rl AdOress <br /> Out of Servlet Well <br /> NEW WELL ❑ WELL REPLACEMENT C) DESTflUCT10N Ll L1 <br /> TYPE Of WELL/PUMP: OTHER nit,oFi Wel, n <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ®( f 171'ir�t <br /> SEWER LINES DISPOSAL FLD. PROP. LINE J <br /> DISTANCE TO NEAREST; SEPTIC TAMC -- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION �— <br /> PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> INTENDED USE TYPE OF WELT Dip, of Well Casing <br /> fl Industrial © Open Bottom C] Manteca Dia. of Well Excavatio?S <br /> Type A i� gapecilications <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy yp of Casin 9 S f rout <br /> Public f 1 Other © Delta Depth of Grout Sea Ty out <br /> ut <br /> Ii Inw <br /> CI Irrigation Approx.'Depth 0 Eastern Surface Seal 11 stailed by <br /> 11 H.P. State Work Done _ <br /> Repair Work Done L3 Type of Pump- Sealing Material i Depth <br /> Well Destruction O Well Diameter Filler Material i Depth <br /> Depth �1 <br /> TYPE OF SEPTIC WORK: NEW iNSTAAI <br /> `FLLATION ED REPRlADDITION 0 DESTRUCTION CI availabe within 200 feetNseptic system r,led if public sewer is 7"' <br /> installation will serve: Residence * Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments V) <br /> SEPTIC TANK- Q Type/Mfg. Capacity <br /> C1 Method of Disposal <br /> PKG. TREATMENT PLT, r <br /> Distance`to Property Line <br /> nearest: Well Foundation _ <br /> LEACHING LINE 0 No. & Length of lines Total length size <br /> FILTER BED 1.1 Distance'to nearest: Well Foundation Property Line <br /> Site Number <br /> SEEPAGE PITS I I Depth i <br /> SUMPS Ll Distance!to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I I ! <br /> 1 hereby certify that I have prepared thin 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 /> 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 she not <br /> employ any person in such manner as toibecome subject to workman's compensation laws of California." ContractoPs hiring or subcontracting signature <br /> certifies the following: •'I certify that in ells 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 applies must call for al quiredlinspections, Complete drawing o (averse side. <br /> f Title: <br /> ZS I L <br /> Signed <br /> F R PARTMSNT USE; ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date��- <br /> Final Inspection by Date <br /> Additional Comments: <br /> 1. <br /> Applicant - Return sIl coplee to: TH SERVICES <br /> ENVIRONMENTALJOAQUIN OHEALTH UNTY UDIVISION BLIC DpERM1T/SERVICES <br /> t� 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT Ot1E AMOUNT REMITTED � RECEIVED BY BATE PERMIT NO. <br /> INFO <br /> . EH 13-74 1REV,i n sI 13 Eli <br /> ` <br /> EH i{•7a <br />