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_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES %.4 <br /> �Q <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I <br /> (Complete in Triplicate) <br /> tall <br /> vork <br /> in <br /> Applicatiis hereby <br /> made,to San vlthuBanin CJoaqufnounty ocounr a ty Ordinance rzit to nNO- 549struct 8and o18628 and the eRules and Regulations dof Sane <br /> application " <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> City 'i <br /> Job AddressA <br /> Q i Phone aZ 16 <br /> Owner's Name Address <br /> I Address <br /> License No Phone <br /> Contractor v WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ MonitoringWelliJ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> SEWER LINES --- DISPOSAL FLD. PROP. LINE <br /> K <br /> DISTANCE TO NEAREST: SEPTIC TAN -- OTHER WELL PITS/SUMPS!f <br /> FOUNDATION _____-�- AGRICULTURE WELL <br /> f t >+\ <br /> iNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS Dia. of Welt Casing <br /> Open Bottom ❑ Manteca Dia. of Well Excavation -- <br /> nindustrial ��lee Specifications <br /> Domestic/Private ❑ Gravel Pack "" ❑ Tracy TYpe of Casing —r - <br /> i-� 0 or ❑ Delta <br /> Depth of Grout Seal ype of G our <br /> ] Public l I <br /> �30 APMoK� Depth Eastern dace Seal installed by <br /> CJ irrigation �� a �p6(ork Dons.— <br /> of Pump H.P. �'fj 40 , <br /> Repair Work Done 0 <br /> Type it Sealing Material i Depth <br /> Well Destruction Well Diameter <br /> _ Filler Material i Depth _ <br /> _ Depth t J%� III I <br /> STYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIRIADDITION Ci DESTRUCTION CI availab e within 200 feetseptic system .) i! public sewer is <br /> Installation will erve: Residence - t Commercial— Other------- <br /> Number of livingr units: Number of beBrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: Capacity.— No:Compartments <br /> SEPTIC TANK ❑ TypelMfg Method of Disposal <br /> PKG. TREATMENT PLT, Cl Property Lina <br /> Distance to nearest: Well Foundation—�-- <br /> -LEACHING-LiNE� L4—No-&'Length-of"N lProperty Lina ... <br /> FILTER BED n Distance to nearest: Well Foundation - <br /> " i »v �Sue � Number _ <br /> r_ SEEPAGE PITS I I Depth t Property tine <br /> SUMPS Ll Distance, to nearest: Weil Foundation <br /> ` DISPOSAL"PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> I l not <br /> rules end ragulefions of the San Joaquin County g Y work for that in the <br /> Home owner or licensed agent's signature cemTg s the olioect to workman's compensation Isrvaoof California," Contractor slhhingr ores blcontract is englsignature <br /> employ any person in such manner as to bete 1 <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. Y <br /> The applicitni must call for all required inspections. Co% 4piete-drawing.on rave►ie s de:s� r� <br /> Title: Date: pl <br /> Signed - <br /> ' R DEPARTMENT.uSE ONLY <br /> Date��I�C� _ Area f <br /> Application Accepted by <br /> Pit or Grout'Inspection by <br /> tgate _ - <br /> incl inspection by Date9`�`-'-' <br /> Additional Comments: Y <br /> Applicant - Return all copies to: ENVIRONMEIN COUNTY PUBLIC HEALTH SERYICB$ <br /> ;R--.�-•- L J S� <br /> NTAL <br /> AI 445INOSAN JOAQUIN,TP 0 BOX I2009ON E STOCKTON, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. !A1 <br /> I FEE AMOUNT DUE�" AMOUNT REMITTED CASH <br /> INFO r/ _ �j' �� � p <br /> r Ehr13•24rPEV.iinsr I 'o-0, <br /> 0� ! ��G 1�0� 7Q f <br /> #H:626 <br />