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r�. <br /> APPLICATION FOR PERMIT <br /> L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON. CA 95201 <br /> PEUX VrAR FROM DA-- <br /> (Complete in Triplicate) <br /> Application i■ hereby made.to•San Joaquin County for a,Peratit to Construct andror'instali the vork hereto described.' this <br /> ,? application to made in compliance with San Joaquin County,ordinanee To. 549 and 1$62 and the Rules and Rajttlatioaa.of But: <br /> Joaquin County Public Health Services- <br /> 0 <br /> ervices.5C/ jfGl)/ Ci� site/Acreage <br /> Job Address <br /> Ownet's Name Address _License No Na: z Z Z� Phone <br /> C s las <br /> Address <br /> of <br /> Out t of Service Vell7• <br /> _ DESTRUCTION QLl <br /> TYPE Of WELLIPUM NEW WELL O :WELL REPLACEMENT f] DESTRUC. HoaitO'Ing Stall, <br /> " PUMP IN LA 0 SYSTEM REPAIR C�- OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP UNE <br /> RI tTUAE WELL OTHER WELL PITS/SUMPS <br /> AG <br /> FD SND 0 <br /> CU <br /> r <br /> ATI N <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> x <br /> 0 Indusirilal ❑Open Bottom 0 Manteca - Dia.of Welf Eacaviiion Ds.. <br /> a!Welt Casing - <br /> C.1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Spircifica[{oM <br /> .. f'I Public C1 011ier - 11 Defta Depth,of Grcut Semi TYPa Grout ` <br /> P r I Irrigation T Approx.Depth - I 1 Eastern Surface Sea!Installed by 1(^" <br /> Repair Work Done ❑ .Type of Pump H.P. State Wark Done <br /> Well Destruction. Q Wall Diameter <br /> Sealing Material i Deytd : r <br /> t - Depth Piller Haterial.i Depth <br /> -:YPE OF SEPTIC WORK: <br /> NEW INSTALLATION REPAIRrADDITiON t Y, DESTRUCTION I I (No septic sistem permuted d public <br /> Sawa <br /> k 9 �vahlabk we r4 las / <br /> . lnatellatian will carve: RMidanx Commercial Other <br /> Nurnbar'of living units: Number o rooms <br /> I _ - <br /> Charm of wN to a depth of 3 fuel: _ Water table dePrh <br /> _� No.Water <br /> ' <br /> SEPTIC TANK. Type/Mf CaPacit <br /> E PKG.TREATMENT PLT.Cl tar <br /> / MetticIf of Dirosal <br /> I - Disnce to nearest: Well� Foundation, 15"-� Property Line_..5 x <br /> r y <br /> No.i3 Length of Lines T9tal length/site �1 <br /> 1 LP <br /> ACHING L <br /> INE g <br /> FILTER BED <br /> Cl Distance to nearest: Wall ZJV Foundation ZO _ Property Line.�,:�.^ `"4 <br /> _ SEEPAGE PITS - eprh Sita Number L <br /> r <br /> SUMPS ! LI Distanceto nearest: Well/�_', Foundation Prupo Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify drat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesstate hyo and <br /> - i rules andreputations of the San Joaquin County - - - -' - - <br /> Homs owner or ktensed agent's signature certifies the following:"I certify that in the performance of the work"for"jeh thIs paimit is Iasuad;-I SMR no[ <br /> ra <br /> employ any poison in such manner as to become subject to workmans compensation laws of California."Contractors hiring Or suaconvectlnq srQnatua- - <br /> Cartifies the fokwing:"I certify that in the perlormance of the work for which this permit is issued.f shall arnoloy persons subject to workman a COmpans <br /> !� Tian Iowa of California." - <br /> - ,The applicant all!or r ssir inspections.Complete drawing on reverse s• e. - - <br /> - Signed i:..e:- Date <br /> s• i FOR DEPARTMENT USE ONLY r. <br /> Date <br /> Application Acc"ted by46 <br /> - Area <br /> or Grout Inspection by 1.Ci.SL { Date tlnaI Inspection by Data <br /> E, !- <br /> .- Additional Comments: <br /> Applicant •- Return all copies to: San Joaquin County Public Health , <br /> Services. Eavironmeetal Health Permit/Services <br /> _ 1601 E. Ratelton Ave.,.P 0 Pox 2009. Stockton. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE I'MMIT'NO.- <br /> - INFO <br /> i -I <br /> .ER t7.2E[atV.ri.ei .- <br /> EN:17a - <br /> k � � <br />