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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC 'HEALTH SERVICES <br /> { ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p. HAZELTON AVE.0 BOX 2009P STOCKTONF- 3420 <br /> CA 95208 <br /> E%P RES 1 YEAR FROM DAT <br /> ED <br /> (Complete in Triplicate) <br /> tall <br /> vork <br /> Applicis hereby <br /> main de.to Sanrice trithuin SanCountyaqulaoCountyr a rOrdinancemit to nnoru549ct a&ndol$62sand the eRules and eRegulations dof Sans <br /> application <br /> Joaquin County Public Health Services. ,"d/ V- <br /> City <br /> V-City Lot Size/Acreage <br /> Job Address <br /> �� Phone <br /> Address 3` 3 <br /> Owner's Name - - Ccs <br /> License No.�� '� Phone <br /> � Address <br /> Contractor /�� DESTRUCTION C1 Out of Service Well ❑ � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LlN£5 ----- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC,TANK — OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> .�.-- }pia. of Well Casing �.�.—•-� : <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> f7 Industrial l '" t : Specifications <br /> C7 TracY—Type-of Casing <br /> [_}'Domestic/PrivatXL ❑ Gravel�ack Type of Grout1-1 Other ❑ Delta Depth of_Grout yeaSurface Seal Installed by <br /> s _ Apprax: Deph l I Eastern I } Irrigation r r 'State Work Done <br /> H.P. <br /> Repan Work Done Type of Pump . 1. <br /> Sealing Material & Depth } <br /> Well Destruction Well Diameter Filler Material S Depth <br /> I j Depthj <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION h Ir DESTRUCTION I N <br /> available rw hin 200 leetc system ��ed if public sewer is <br />` f I <br /> Installation will see:rflesidence ---Commeicil Other�' "" k �t f <br /> Number of living units: �� Number of be roams Water table depth t <br /> Character of soil to s.dripth of 3 feet'. Gapacity__416--_�--- No. Compartments <br /> SEPTIC TANK. FGY Type/Mfg „ : / a Method of Disposal <br /> it <br /> PKG. TREATMENT PLT. -, Property Line Q <br /> I `I Distance to nearest: ,Well Foundation <br /> To a1 leng�,p.rty <br /> ` ` <br /> LEACHING LINE _L No._f4 l-ength,oUtines., <br /> ' Foundation o Pine <br /> FILTER BEDCI Distance to nearest: ail ' <br /> s _ <br /> IL3 "Depth � � •� Size � Number <br /> SEEPAGE PITS Foundation = Property Line t �� <br /> SUMPS ' Cl Distance to nearest:. Well <br /> + DISPOSAL PONDS ❑ <br /> F I hereby certify that{ have prepared this application and that tie work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of,the,San Joaquin County f,_ 1�1 <br /> Home owner or licensed agent's signature certifies the lollowingi"'I certify hat in the performance at the work for which this permit is issued, l signature <br /> shall not <br /> s of California." <br /> employ any person in such man;hat n the performancet to he work foswh ch this permit ation is issued, I shall employaperrsonsrring subj subject to workmanub-contractrsgcompensa <br /> certifies the following:"1 certify r <br /> tion laws of California." f <br /> t <br /> The applicant must call for all requir in ctions. Complete drawing on reverse side, i p <br /> 1 4 e <br /> t Title: Date: <br /> Signed t" t <br /> t FOR DEPARTMENT USE ONLY t <br /> r t" Date Area <br /> ;i, <br /> plication Accepted by fGL�G' <br /> f <br /> 6-1 Inspection by ate -�-- <br /> or Grout inspection by T __ _ Date f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> i Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RMIT'NO. <br /> 1,9 <br /> ffW <br /> AMOUNT REMITTED RECEIVED 9Y DATE <br /> DUE CASH <br /> . EH 13-24 iREV.1 1"5) <br /> EH S4-IE <br />