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APPLICATION FOR PERMIT <br /> S"—JOAQUIN COUNTY PUBLIC HEALTH Jr;RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> IRES 1 YEAR FROM DA Fly <br /> (Complete in Triplicate) <br /> pplication is hereby made to San,Joaquin County for a ' <br /> application County <br /> made in Health <br /> S ry With San Joaquin county install <br /> theeRules herein described. This <br /> Joaquin County Public Health Services. <br /> �-, Ael3+ilations of San <br /> Job Address <br /> 9 <br /> City Lot Size/Acreage <br /> Owner's Name <br /> ddress <br /> Phone <br /> Contractor .-- <br /> i ess <br /> TYPE OF WE L P p; NEW ense 1Vo Phone <br /> LL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION E3DES7 U TfON Q Out or service Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER C) Monitoring Well <br /> --- SEWER LINES ❑ <br /> FOUNDATION "�— -�- DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION PITS/SUMPS <br /> n <br /> j industrial ❑ Open Bottom —Ma " <br /> C:I <br /> Domestic/Private Manteca Dia. of Well Excavation <br /> ❑ Gravel Pack n Tracy 7 Dia. of Well Casing <br /> I'I Public I:1 Other Type of Casing Specifications <br /> I I Irrigation f 7 Delta Depth of Grout Seal <br /> —Approx. Depth I 1 Eastern Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done U i <br /> Type of Pump �� H.P. <br /> Well Destruction ❑ Well Diameter T` Sealing Material & Depth State Work Done„ <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INS/TALI�4TION I REPAIR/ADDITION I I DESTRUCTION ! I (No septic system <br /> Installation will serve; Residence r Aermitted it public Sewer is <br /> Commercial,.� available within 200 feet.) <br /> Number of living units: Other <br /> Number a} bedrooms__ILL <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT, ❑ 7EW�:�� Capacity No. Compartments RR' <br /> Distance to nearest: WellMethod of Disposal I' <br /> Foundation` property Line <br /> LEACHING LINE ❑ fro- & Length of lines �^ <br /> FILTER BEDC] Total length/size Q <br /> Distance to nearest: Well �y <br /> Foundation�` property Line <br /> SE AGE PITS 11 Depth <br /> Size Number <br /> L <br /> CI Distance to nearest: Well rr <br /> DISPOSAL PONDS ❑ t- Foundation,/Q`Q_ Property Line <br /> I hereby certify that l have prepared-this application and that the work' <br /> til be done in accordance with San Joaquin ecu <br /> rules and regulations of the San Joaquin County <br /> Nome owner or licensed agent's signature certifies the following: y performance <br /> q county ordinances, state Paws, a d <br /> employ an g: "I certify that in the rformance of the work for which this permit is issued, I shall not <br /> p Y y 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 o}the work for which this permit is issued, I shall employ <br /> tion Jaws of California." p p y persons subject to workman's compensa- <br /> The applicant sl cal for all requir coons. Com et yawing on.reverse side. { <br /> Signed <br /> Tide: <br /> Date: <br /> S�� FONT USE OII,LY <br /> Application Accepted by <br /> Pit or Grout Inspection b _ Date <br /> � Area <br /> y ` � Date <br /> `"!G ---� Final Inspection by <br /> Additional Comments: / �! C , Date ^ <br /> Applicant - <br /> Return all copies <br /> ta: San Joaquin County Public Health <br /> Services, Ravironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009 Stockton CA 95201 <br /> FEE x rA <br /> INFO MOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIV h By DATE <br /> 1IREV.vKsi O PERMIT'NO. <br /> EHI-24 <br /> o�c f n <br />