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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONN[ENTAL HEALTH DIVISION <br /> 1601 p+O BOX 2009`, S <br /> VTOCKTON, CA95201 <br /> EX17 RES 1 YEAR FROG T ED a <br /> (Complete in Triplicate) . .� <br /> in <br /> ( Application is hereby made,iiaSan rJr�h Joaquin County yrordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> a.nd thethe <br /> Rules and eRegulations dof Sans <br /> [ application is made in comp <br /> Joaquin County Public Health Services. �} <br /> • C1 City( 'C� Lot Size/Acreage - <br /> Job Address -, GP <br /> !! )SaPhone <br /> L Address <br /> Owner's Name <br /> ense.No_r-, Phone <br /> ` Address- Lic . ___�. <br /> --Contractor - -� • .-- I__ -. <br /> WELL WELL REPLACEMENT C7 DESTRUCTION C7 Out of. Service well ❑ <br /> TYPE OF WELLIPUMW WE <br /> P: OTHER ❑ Monitoring Well Ll <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> SEWER LINES ' — DISPOSAL FLD. PROP. LINE <br /> ,�/� r <br /> a ,DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPSAS0 <br /> FOUNDATION <br /> ,r <br /> s <br /> INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC <br /> IFICATIONS pia. of Well Casing <br /> Open Bottom C] Manteca Dia. of Well Excavat' <br /> {� Industrial Specifications <br /> pomesticl.Pr,ivate _0 Gravel Pack ❑ Trac_ Type of Casing �._ ..Y.--.,�,,..-�..� -- — Ty of Grout�r=.F1 Delta Depth of Grout SealI'1 Public i:lrQthyr3A rax, Det I as ern urface Seal tnstal4ed <br /> I I irrigation pp �,, P State Work Done ` <br /> 5 H.P. r <br /> Repair Work Done L7 Type of Pump Sealing r Material & Depth <br /> Well Destruction 'O Well Diameter <br /> Depth I F`� Filler Material & Depth + . <br /> TYPE-OF SEPTIC WORK: --NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I iNOilabpticle Syst m permitted if public sewer is' <br /> k Installation will serve: Residence^ Commercial Other y <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 fest: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> -, Method of Disposal <br /> PKG, TREATMENT PLT. Ci '- <br /> Distance to nearest: Well Foundation '` ;F <br /> Total length/size <br /> LEACHING LINE ❑ No. &iLength of lines Property Line <br /> I FILTER BED CI Distance to nearest: Well Foundation <br /> AGE PITS 1 1 Depth Sire Number <br /> SEEP C� <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line T� <br /> I 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, an \ <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's sigriature certifies the following: "I certify that in the performance of the work for which this permit is.issued. I,shatl not <br /> employ any person in such manner as to become Subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: u certify that s the performance of the work for which this permit is issued,'l shall.empl°y persons subject to-woikman's compensa- <br /> tion laws of California." k <br /> The applicant must call for all required 'nspections.complete drawing on reverse side: <br /> Signed Title: . <br /> Date: <br /> I FOR DEPARTMENT USE ONLY <br /> Date <br /> Area <br /> Appl"' t' n Accepted by <br /> r Date inal Inspection by <br /> Date <br /> Pit or ro Inspection by <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Perriiit/services�3' - <br /> --'^^"" 1601 E: fieaelton pve."P'0•Buil 2009,Stockton,CA95201 <br /> ' CK <br /> FEE PERMIT NO. <br /> MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> INFO GASH (J <br /> + Eli 13.24 tREV. <br /> EH 14.26 <br />