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I <br /> APPLICATION FOR PERMIT '+ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 y <br /> (209) 468-3447 <br /> k <br /> 1 (Complete in Triplicate) <br /> vork <br /> Application-is hereby 'Ldee,,tO San Vo�hui�CJ�QuinQGounr a ty Ordinancermit to nNo�5k9ct sandol862aand thetall eRules eadeRegulationein dof Sana <br /> application Is toad CVS , <br /> Joaquin County Public Health Services. fffrwln� { <br /> CityDl Lot Size/Acreage A <br /> Jot) Address ��' �` f <br /> 74 <br /> Phone -3 - <br /> Address <br /> Owner's Name. <br /> " .GT ��License No. ����Phone <br /> Contractor— ' - Address y !417 <br /> NEW WELL ❑ WELL REPLA....EMENT ❑ O1:STRUCTkON ❑ Out of Service titell L + <br /> TYPE OF WELLIPUMP: OTHER p Monitoring Well <br /> PUMP INSTALLATION 13 <br /> REPAIR ❑ <br /> DISPOSAL FLD._ PROP. LINE <br /> SEWER LINES .� — PITS/SUMPS <br /> .� <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- AGRICULTURE WELL OTHER WELL^-..-- <br /> FOUNDATION ._ �J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing v <br /> jI O Opsn Bottom �0.MantecaofWell Excavation <br /> [71 Industrial <br /> Specifications <br /> L7 Tracy Type of Casing <br /> U Domestic/Private C) Greve] Pack Depth of Grout Seal Type of Grout <br /> Cl PubiiC i'1 Other i ❑ Delta O <br /> CI Irrsoation .� Approx. Depth ❑ Eastern Surface Seal Installed State Work Done, <br /> (.-.j <br /> Repair Work Done U Type at Pump H.P.Sealing Material & Depth LL✓✓ <br /> Well Destruction O Well Diameter} — Filler Material & Depth <br /> .Depth armitied <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ tc system <br /> REPAIRIADOITION _ DESTRUCTION CI aNailabPelw thin 200 feet.) it public sower is <br /> Ott <br /> 4 le <br /> installation will serve; Residenc ` Commercial Other <br /> e <br /> Number of living units: L Number of bedrooms <br /> �`. Water table depth <br /> Character of soil to a depth of 3 feet:r No Compartments Z <br /> SEPTIC TANK ❑ Type/Mfg - Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ yS� <br /> Distance to neareif: Wel Foundation s Property Line <br /> Total length/size <br /> LEACHING LINE C'1 No. a of lines Property Line --- <br /> FILTER BED is Distance to nares . Watt�� Foundation - � <br /> f <br /> j 1 Size Number <br /> I SEEPAGE PITS l I Depth Property Line �- <br /> SUMPS Lt Distance io nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> 1 F <br /> rk will be done in accordance with San Joaq`u,h county ordinances, state taws, an <br /> I hereby certify that I have prepared this application and that the wo <br /> rules and regulations of the San Joaquin County <br /> _ o4lowing, "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the f <br /> cervil the person in suchmannerman shat n the come subject <br /> bjece t f the work foto swh cheth s permit nsation tis issued,s of I shall employ apersons fsubj ct t workman's compensa- <br /> tion laws of California." r <br /> The applicant must call for all required inspections. Cc"to drawing on reverse e. 91 <br /> LTitle:4 i 6/�J Date: - -. <br /> r Signed <br /> FOR DEPARTMENT USE-ONLY <br /> �JlfDa� ,72'�/ Area <br /> f Application Accepted by 2 <br /> Pit or Grout Inspection by Date <br /> 'Final Inspection by Date <br /> . r <br /> 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 <br /> FEE CK RECfiIVt2D 8Y DATE PERMIT'NO. <br /> INFO MOUNT DUE AMOUNT 9EMITTED CASH <br /> . EH 13.24 IREV. <br /> EH?4.26 <br />