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APPLICATION FOR PERMIT : <br /> SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> p T SSPIRES <br /> FEAR FROM DATE S ' <br /> (Complete in Triplicate) z <br /> Application is hereby made to San JoaquiinCo� uinfor <br /> a permit <br /> ordiee tno construct and/or <br /> end install <br /> ttheAwork <br /> haadedescribRegulationedof mSans 4 <br /> application is made in compliance <br /> Joaquin County Public Health Services. �+ <br /> ity Lot Size/Acreige <br /> Job Address <br /> Phone'; ZZAddress <br /> .` <br /> Owner's Name �'• t1p _ <br /> hone <br /> i <br /> t <br /> Conti actor �-ddfess - <br /> TYPE OF WELLIPUMP: NEW WEL _ WELL REPLACEMENT Cl DESTRUCTION ❑ tit of Service Well O <br /> PUMP kNSTALLATION SYSTEM REPAIR .0 <br /> OTHER ❑ Monitoring well <br /> "}SEWER LINES DISPOSAL FLD. '"�- PROF..LkNE �� <br /> DISTANCE TO NEAREST: SEPTIC TANK . OTHER WELL PITS/BLIMPS <br /> FOUNDATION � AGRICULTURE WELL � <br /> INTENDED USE TYPE OF WELL PflOBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing;; <br /> 0 Industrial ❑ Open Bottom ❑ Manteca ;f <br /> e Gravel Pack ❑ Tracy <br /> Type of Casing_ �� Specifications -- <br /> -Domestic/Private Type o1 Grout <br /> Cl Other n Delta Depth of Grout Seat 4C <br /> I'1 Public f - <br /> i tIrrigation Approx Dept�h, ff IIa I��Eastern Surface Soul-Installed by �r <br /> of Pump k H.P _ State Work Dona = <br /> Repair Work Done U Type Sealing Material i Depth <br /> Wolf Destruction 0 Well Diameter r <br /> i Filler Material i Depth <br /> Degih <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIfl/ADDITION I I DESTRUCTION availablerwthine200 feet.) <br /> Installation <br /> public sewer is <br /> Installation will serve: Residence_-- Commercial^ Other <br /> Number of living units: Number of bedrooms u, Water table depth ' <br /> Character of sop to a depth of 3 feet: No. Compartments <br /> Capacity- <br /> ',-Method <br /> SEPTIC TANK ❑ Type/Mfg y — <br /> ',Method of Disposal `Y i — <br /> PKG. TREATMENT PLT. ❑ �':� ` ! i <br /> Distance to nearest: Well Foundation Property Line_ 1 <br /> Total length/ <br /> LEACHING LINE 0 No. & Length of lines Propel_=�- ' t <br /> FILTER BED Distance to nearest: Well <br /> C) Foundation <br /> SEEPAGE PITS I 1 Depth - ` Si:a '- t Number <br /> .d oun aaon.f- <br /> ' A Prop 4rty Line <br /> aa <br /> SUMPS Ll Distance to rrreii." - Welles <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be coria in.accordartce with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County f7— ; <br /> Hortta_ownar or licensed agent's signature certifies the following: "l certify that in the performallce_at she work for which this permit is issued, I Shap not <br /> employ any person in such manner as to become subject to workmen's compensation taws:pfCaiifornia�Contracior s hiring or subcontracting signature <br /> certifies the following: ,I 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." <br /> a <br /> The applicant r�t r I r tions. Complete drawing on raver side. - <br /> k <br /> Date: <br /> Signed <br /> i DEPARTMENT USE ONL <br /> � - Date�`���� Area <br /> Application Accepted by <br /> Date Final Inspection by�� `,/�'�=s Date <br /> Pk of t Inspection by ei <br /> Additlonal�Commsnts: , <br /> Applicant - Return all copies to: San Joaquin County,;,Public Health Services' <br /> i Environmental Health Permit/Services [y�� <br /> 445 N San Joaquin, P'VBoz`2009L, Stkn, CA 95201 <br /> FEE RECEIVED BY DATE PERMIT N0, <br /> INFO AMOUNT DGE AMOVNT REMITTED CASH x <br /> EH 1445 / _ <br />