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APPLICATION FOR PERMIT q <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />'i ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> LERMIT .EXPIRES I YEAR FROM DATE ISNED , <br /> ! (Complete in Triplicate) <br /> r _ vork <br /> Application is madein <br /> cc0pljan�,Jvjthuin SanCounty Joaquin Counr a ty ordirmit nancenstruct No. 549Aando1862sand theeRules andeRegul„ations of Sans <br /> application is made i otsp <br /> Joaquin County Public Health Services. ; <br /> -41 Lot Size/Acreage <br /> /. f �.e�r City rJ► <br /> Joh Address �� - - <br /> Phon <br /> Owner's Name <br /> n � Address <br /> i <br /> G -acQ X27-3 Phones <br /> r Contractor Address License No <br /> L REPLACEMENT DESTRUCTION C <br /> TYPE Of WELL/PUMP: NEW WELL 131 Out of Service Well ❑ <br /> WELL CJ <br /> PUMP INSTALLATION ❑ SY.STEM REPAIR [ <br /> OTHER ❑ Monitoring Well C7 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> C) Industrial ❑ Open Bottom 0 Manteca Dia. of Well Eltcavation_ Specifications <br /> 6f Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing!_ <br /> l-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> i'I Public 1 { . <br /> i I Ire anon �.Approlt. Oept I I Eastern Surface Seal Installed by <br /> t " - State Work Done_— <br /> Repair <br /> Work Done (t3 Type of Pump H P Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter biller Material i Depth <br /> Depth <br /> TYPE O€ SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION-1 i allo..sevailabpetwthisystem permIrmined i! public sower is ' <br /> y <br /> Installation will carve: Residence Commercial_..,,^ Other <br /> Number of living units: Number of bedrooms , <br /> Water table depth <br /> Character of sole to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKC. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line <br /> 1 ' <br /> LEACHING LINE 0 No. & Length of linee Total len t' / ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation iropeny Lina <br /> I , <br /> SEEPAGE PITS l 1 Depth Size Number <br /> f <br /> SUMPS LI Distance to nearest: Well Foundation roperty Lina <br /> DISPOSAL PONDS ❑ 1 } <br /> I hereby eenify that I have prepared this application and that the work will be done in accordance wi h San Joaquin county ordinances, stats laves, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of,he work for which this permit is issued, I shall not <br /> employ any person in such manner asito become subject to workman's compensation laws of Coliform ." Contractor's hiring or cub contracting ltignatur <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I ahattN employ persons subject to workmen's Compensa <br /> tion laws of California." I <br /> I� I <br /> The applicant t c I for all r utred inspections. Complete drawing on reverse side. <br /> -.>2 `�2 <br /> Signed Ile Date: <br /> O NT USE ONLYro f,. <br /> Application Accepted by <br /> Date _ Area <br /> NC U/53 <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> f Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEiVE4 BY DATE PERMIT'ND. <br /> INFO <br /> . EM 13.24IREV.IIx51 ' ©- Ys! ILa-9- <br /> EH 14-M nnn <br /> k _. <br />