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APPLICATION FOUR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCCKTON, CA 95201. <br /> P T EXPIRE 1 YE FROM DA TE SII <br /> j (Complete in Triplicate) <br /> f j. <br /> Application is hereby msde•to San Joaquin County for a permit to construe aanidoinstall eherein work <br /> 1862 and the Rules andRegu]ationsof Sans <br /> application in made in Compliance with Ban Joaquin County Ordinance No. 5 9 <br /> Joaquin County Public Health Servi'4 s. <br /> City Lot Size/Acreage <br /> Job Addre t <br /> hone <br /> Address <br /> Owner's Name <br /> s ! <br /> Contractor Address <br /> oZ License No.�-Phone <br /> TYPE OF WELLlPUMP: NE WELL�" ` WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Mo Service Well G1 <br /> OTHER O Monitoring Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ ✓ <br /> DISTANCE TO NEAREST: SEPTIC TANK r '"SEWER LINES LW <br /> DISPOSAL FLO. PROP. LINE <br /> � lk WELL" '• """OTHER WELL`=M PITS/SUMPS I_aS <br /> FOUNDATION AGRICULTU <br /> , rr <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S pia. of Well Casing <br /> _ C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex vation - <br /> T f Casing Specifications <br /> IDomastic/Private Gravel Pack ❑ Tracy y oType Of root t e <br /> !"1 Other Depth of Grout Seal <br /> Il Public ��11 Cl Delta f h <br /> i I kriigations�APprorr,i Dep;h I I Eastern Surface Sea] Installed by q ,I 6SS <br /> Rspakr Work-Done "❑ Type of Pump, H.P• <br /> State Work Done - <br /> ,a A Sealing Material i Depth <br /> Welesru ❑ Wall Diameter <br /> Well Destruction - -._ <br /> pillare"Nate.rial A Depth <br /> � pepth ' <br /> TYPE OF SEPTIC WORK: -NEW INSTALl11710N I I REPAIR!ADDITION I IRESTflUCTION l I available{w Thin 200 loot.)c system ed i1public 6ewar is <br /> 'Installation will serve: A"clence— I Commercial�r Other `• <br /> Number of living units: Number of bedrooms ` t Y+ �,i �--+. - - <br /> Water table dipth <br /> Character of Boll to a depth of 3 feet: - <br /> ,' Capacity.-.. ..-.---- No. Compartments <br /> SEPTIC TANK. 0 " Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.Cl property Lina <br /> II Well ntion �- <br /> Distance to nearest: '. Founda <br /> M <br /> . Total length/size T <br /> LEACHING LINE i D No. 8 Length of linea pro Line <br /> i FILTER BED �'o Distance to nearest.- Well Foundation Pent <br /> SEEPAGE PITS ` l I- Depth Size Number <br /> ' <br /> SUMPS Ll Distance to nearest: Wall Foundation_-__..___— Property Line <br /> ' � ` <br /> DISPOSAL PONDS /❑ <br /> I 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 Ind regulations of the San Joaquin County <br /> Homs owner of licensed ayenfa signal <br /> cerlitisi the iollb-wing:LL"1 certify that in the performance of iha work for wFiich this p mit is issued, I shall n, <br /> employ any person in such manner as to became subject to workman's compensation laws of California." Contractors hiring or sub-contracting signstur <br /> certifies the fotlovAng: "1 Certify that in the performance of the work for which this permit is issued,k shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all roquira4 insPections:Complete drawing on reverse sid . <br /> Title: — Date: <br /> i Signed h ^_ <br /> �FOD�EPARMENT USE`gNLY 3 Q� , � G. <br /> Date Area <br /> Application Accepted by A3 <br /> Pit Grout tion by. ate <br /> w 3 Final Inspection by Date -- <br /> Ci P9.3-A rO` <br /> ► Additional Comments: - -- <br /> ..._ -. <br /> App licant"---Re.turn-al l_copies_to:---3an..Joaquin-rCounty-Public-He ELI th•Services <br /> EM <br /> Health Permit/Services 3 <br /> EM N San Joaquin, P O Box 2009, Stkn, CA 95201 # <br /> i FEEMHM!J2 RECEIVED 9Y DATE PERMIT'NO. <br /> j INFOEH 13.24(Rev.I/Mal <br /> ` EH 11.26 <br /> l• <br />