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APPLICATION <br /> G' { SAN JOAQUIN COUNTY PUBLIC HEALTH!SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,PHONE(209)469-3420' <br /> P O BOX 388, STOCKTON,CA 95201110388 <br /> PERMIT EXPIRES .1 YEAR FROM DATE ISSUED <br /> LNVIRONMENTALHEALT {Complete in Triplicate) <br /> PERMIT l SERVICES. k herein F <br /> A plication is hereby made to San Joaquin County for a permit 10 construct and/or Rules and Rethe siagulation <br /> ulations'lof San Joaquin County described.This tpubl Health Services.compliance <br /> wuh San <br /> P <br /> Joaquin County Development Title Section 9-1110.3 and Section 9 1115.3 and the B Ii <br /> City Lot Size/Acreage <br /> Job Address <br /> �,. <br /> / Address 'got Phone . <br /> Owner's Name <br /> Address 'X ��0� —Phone • <br /> i Contractor DESTRUCTION CI Out of Service Wall L1 <br /> TYPE OF WELLIP MP: NEW WELL © WELL REPLACEMENT Cl J Monitoring Well C] <br /> PUMP INSTALLATION G N SYSTEM REPAIR C7 OTHER LTJ �py� Yl� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE-7 J <br /> DISTANCE TO NEAREST: SEPTIC TANK ---`�' 'I '} <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> Il <br /> tJlJ��1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA "ONS it a� �+rsJ ` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiori <br /> 8 __� Ois• of all Casin <br /> Type of Casing_ ! Specifications <br /> (1 Domestic/Private ❑ Gravel Pack 0 Tracy I� I �' Type of Grout <br /> I"1 Public I:1 Other I1 Delta Depth of Grout SsaI1 <br /> :f <br /> t I Irrigation Apil Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. Slats Work Dons <br /> Sealing Material i Depth (A� <br /> Well Destruction ❑ Well Diameter Filler Material A Depth l i <br /> Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I I fNo septic system permitted it public sower is <br /> �j available within 200 feet.} <br /> Installation will serve: Resid Commercial — Other <br /> 3i <br /> Number of living units: Number of bedrooms <br /> Character of soil to pth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity II No. ComPartments <br /> Method of Disposal <br /> PKC. TREAT NT PLT. ❑ I <br /> Distance to nearest: Well - Foundation i Ptopeny Line <br /> LEACHING LINE ❑ 8 Length of lines Total length/site' <br /> FILTER BED Distance to nearest: Well Foundation Ij Property Line <br /> ij <br /> SEEPAGE PITS <br /> 11 Depth Size Number.,E <br /> SUMPS LI Distance to nearest: Well Foundation h Property Line <br /> DISPO L PONDS ❑ :I <br /> 1 hereby certify that I 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 o1 the San Joaquin County 1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the partorm nce of the work for which this permit is issued, I shall not <br /> employ any person in such mannat 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 isaued, I shiill employ persons subject to workman's compensa- <br /> tion laws of Califorrila." <br /> The applican must call for_, required inspections. Complete drawing on verse side. ♦ tSQ4? <br /> µ , I E ,LI� <br /> `� t .I <br /> i . <br /> R DEPART iN T USE ONLY, <br /> Application Accepted by Date A►ea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmcniai Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,t A 95201'0388 <br /> li. <br /> INFO AMOUNT DUE AMOUNT REMITTED C <br /> IL <br /> EH 567e �/] RECEIVED 8y DATE fvP`IE-R1�M7I7�N0. <br /> EM iS-N iREv.rina� 1161ASH <br /> qZ ���r r! I �"' 'G�� <br />