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APPLICATION FOR PERMIT t <br /> r SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> .' ENVIRONMENTAL HEALTH DIVISION , <br /> -� P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> Applicais hisadebin compllan�elvithuin SanCJoaquinor a county ordinancermit to nstruct No. 549gand�1862s� theeRules and�Regulationsdof Sans <br /> application <br /> Joaquin County Public Health Services. �O f '�f <br /> City <br /> �� Lot Sit a/Acreage <br /> Job Address ._ <br /> �..�.__� •- <br /> l:k ' <br /> .�. _ <br /> -A 'Phone <br /> Address f✓ <br /> r . -� <br /> Owner's Name af <br /> License No. 46L Phone <br /> Contiactor Address <br />' EW WELL WELL REPLACEMENT l7 DESTRUCTION Out of Service Hell C1 <br /> I TYPE OF WELL/PUMP: OTHER ❑ Monitoring tiiekl [7 <br />' PUMP INSTALLATION! SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK -. I' <br /> SEWER LINES — DISPOSAL FLD.'r PROP. LINE f <br /> FOUNDATION i��J AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> ,F- <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS bia. of Well Casing <br /> Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Industri l ❑ Specilications <br /> L] Domestic/Private ,KGfovel Pack C7 Tracy Type of Casing �. <br /> Type of Grout <br /> M Public to Other i ❑ Delta Depth of Grout Seal <br /> rriUalianApprox. Depth ❑ Eastern $�eCe seal Installed by t <br /> H.p State Work Dona-_ <br /> Repair Work Done D Type of Pump Sealing Material & Depth <br /> Well Destruction O Well Diametr --- Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted it public sewer is <br /> available within 200 test-1 <br /> Installation will serve: Residence�� Commercial— Other i <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of &oil to a depth of 3 feet: No. Compartments <br /> ' Capacity <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.C1 ! <br /> Distance to nearest: Well Foundation property Line <br /> 1 LEACHING LINE 0 No. & Length of lines f Total length/size <br /> F Property Line I ; <br /> FILTER BED (7 Distance to nearest: Well s Foundation p Y 4 <br /> SEEPAGE PITS 11 Depth f 1 Sue �_ �. �_ <br /> Number <br /> SUMPS LI Distance to nearest: Weil"� 1, Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <br /> that the_work'will be done in.accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and <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 the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compe65ation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; -I certify that in the performance of <br /> the work for which this parmit.is issued, I shall employ persons subject to workman's compensa <br /> tion taws of California." <br /> i <br /> The applicant m I aquirll tions, Complete drawing on reverse`sideT- ,• - <br /> Title: <br /> Signed pate: <br /> Op PA tTMENT USE ONLY <br /> Application Accepted by 51 <br /> r Date Area <br /> Date- Final Inspection-by �/�. Data <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLI gAL H SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> f 445 N SAN JOAQUIN,, P O,HOX,2009, STOCXTON� CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED L CASH AECEiVED BY DATE PERMIT NO. <br /> INFO `�$ $; Lo <br /> . EH 13.24IREV.%/X*s -_W�-h. <br /> EN 9420. ,,,, -- <br />