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T APPLICATION FOR PERMIT..- <br /> - " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I R NMENTAL HEALTH 009 STOCKY N, CAI 95201 <br /> SION <br /> pOgOX2 , <br /> (209) 468-3447 <br /> Y R <br /> (Complete is Triplicate) <br /> Application is hereby made,to Sda;Jou ncountyinocounty ordinancermit to nstruct No. 549&ando1862a and thaeRules �dwork eRegulations in dof Saab <br /> application is made in compliance with <br /> OI <br /> Joaquin County Public Health Services. <br /> }^���1, Cit 6 B Lot size/Acreage <br /> :5_ <br /> Job Address 'f i <br /> Phone <br /> �P-Lt PY Address <br /> Owner's Name �1�d Phone <br /> for Address d ..S N EN.so License No,� <br /> Con trac �--- WELL R£PLACEM DESTRUCTION ❑ Out of Service well <br /> NEW WELL ❑ OTHER ❑ Monitoring <br /> TYPE OF WELLlPUMP'- SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION Q DISPOSAL FLD,_ PROP. LINE <br /> SEWER LINES �-=--�— �.– <br /> DISTANCE TO NEAREST: SEPTIC TANK _.�--� AGRICULTURE WELL OTHER WELL____----- <br /> PITS/SUMPS <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> INTENDED USE p Manteca D'++a, of Well Excavation <br /> C� industrial ❑ Open Bottom Specifications <br /> C] Tracy Type of Casing <br /> A omoslic/Private 0 Gravel Pack Type of Grout <br /> 1-1 Other 0 Delta Depth of Grout Seal <br /> ❑ Public $urf Ce Saul Installed by t ,t <br /> CI irrigation • ____.App{orc• Depth Eastern State Work Done <br /> ' H.P. + <br /> Repair Work Done i Typo of Pump Sealing Material fr Depth <br /> Well Destruction ( Well Diameter -- Biller Material i Depth <br /> Depth i -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L� REPAIRlADDITION 1<I RESTRUCTION G ahvaitabpervvithin 200 feetu`ed if public sewer is <br /> installation will save: .Residence Commercial— Other <br /> — <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: CapaCitY�--�---- No. Compartments <br /> SEPTIC TANK 0 Type IMfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation.— Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines Foundation Property Line <br /> FILTER BED .1 Distance to nearest: Well <br /> 1 4 <br /> Sire Number <br /> SEEPAGE PITS I I Depth Property Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation�--- <br /> L� <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sista laws, an <br /> rules and regulations of the San Joaquin County <br /> Hama owner or licensed agent's signature certifies the following, "I certify ify that in the performance of the work for which this permit is issued, l shall not <br /> employ any person In such manner n to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting 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." r <br /> t <br /> The applicant $t all for all r fired i spections. Complete drawing on reverse side <br /> -- Date: <br /> : <br /> Signed title <br /> LI �tFDR DEPARTMENT 'USE ONLY r <br /> Data Area ` <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Dots <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 /> K Y RECEIVED BY DATE PERMIT No. <br /> FEE AMOUNT DUE AMOUNT REMrrIEO CASH <br /> INFO <br /> EM 1344 tREV.r/nal �� r �� 10 <br /> EH;1•M <br />