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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL +HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ISSUEDY <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> Application is made inMil l Saniance jooaquinwith county <br /> aquinoCounr a ty Ordinance rmit to nNo. 549struct fland o1862aand the tall eRules amdeRegulations dof Sans <br /> application <br /> Joaquin County Public Health Services. <br /> Size/Ac <br /> City a7 I ._._� Lot size/Acreage <br /> Job Address C� <br /> Phone �SS <br /> Owner's Name Address•••_�,�,,.,_-�-•- <br /> �. _ _ BO Address_� ��L� i License No. Phone s" 9 <br /> Contrattor ,_ F��p / D___ <br /> TYPE OF WELL/PUMP! NEW WELL `WELL REPLACEMENT C �' DESTRUCTION Cl t'Monitoring Wellwell <br /> SYSTEM REPAIR -- `t BOTHER ❑ <br /> PUMP INSTALLATION~❑ l -^ "` DISPOSAL FLD, _ PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES I PITS/SUMPS <br /> Dia. of Wel! Casing <br /> D Open Bottom ❑ Manteca` <br /> FOUNDATION ��- <br /> RICULTURE WE OTHER WELL' <br /> OF WELL PROBLEM EA ; ST-AUCTION SPECIFICATIONS' <br /> INTENDED USE TYPE <br /> Dia; of.Well_.Excavalion.� <br /> C� Industrial ,rn Specilications (tom <br /> T �3 1 <br /> LJ Domestic/Privets Cl Grave! Pack L] Tracy Type of Casing epth al Grout SeatT � " { Type of Grout <br /> 111 Public " I:1 Other ©Del <br /> s <br /> Cl fnigation Approx. Depth astern S ace Seal instalied.by <br /> l H.P. <br /> Statir Work;'D'one _ <br />' Repair Work Done. L7 Type of Pump Sealing Hater i i Depth <br /> Welt Destructron ❑ Well Diameter Filler Material It Depth <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1REPAIRIADOITION DESTRUCTION �I,:•avaailablelw thstem )in 200 feetpermitted if public sewer is <br /> Installation will serve: Residencea / Commerciale <br /> v Y, <br /> Number of sluing units; L Number of bedrooms APOP Water table depth Jr <br /> Character of soil to a depth of 3 feet. aD <br /> SIC ls�rri� U Capacity �6�� No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg Method of Disposal <br /> f PKG. TREATMENT PLT.0 °` "` <br /> i Distance to nearest: Well Foundation Property Line. ° <br /> LEACHING LINE No. & Length of lines <br /> Total length/size r <br /> FILTER BED n Distance to nearest: Well <br /> Foundation — Property Line <br /> ��` � <br /> SEEPAGE PITS 11 Depth Size Number <br /> �- <br /> SUMPS ,'I< Distance to nearest: Welt�� foundation 3 d r Property Line � f <br /> DISPOSAL PONDS ❑ <br /> s application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> I hereby cantly that l have prepared thi <br /> rules and regulations of the Sen Joaquin county <br /> ertify that in the performance al the work for which this permit is issued, I aha not <br /> Home owner or licensed agent's signature certifies the following: "I c <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> t certifies the following: "E certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant must call for all required insPections. Complete drawing on reverse side <br /> Title: epi Date: <br /> Signedr Q <br /> Oil EPARTMENT USE ONLY q <br /> Appli tion Ac Pted by <br /> 1 Data � ~ L� Area <br /> . <br /> t ipection by <br /> Dat Final lnspectio Data G <br /> I Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC.HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 �y <br /> CK RECEIVED BY DATE PERMIT <br /> FEE NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> I . EHt3•NiFIEv.iinsl y �Y/ —.p � o <br /> EN 1.4.25 <br />