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# APPLICATION FOR PERMIT <br /> �jdE3AQTI COUNTY PUBLIC HEALTH SERVICES <br /> REC I RONMENTAL HEALTH DIVISION <br /> p U $ ,q 2009, STOCKTON, CA 95201 <br /> U (209) 468-3447 <br /> ' SAN JdAQUIN CCIUN TY - <br /> PUBLIC F <br /> LNVIRO'�MENTAL��EALI:(C��PZ"ate 1>a Triplicate) � <br /> I vork <br /> Applicie haadebkn cor>xplianceivSan ith SanCJoaquinacounr a ty Ordinancermit to nNo. 549struct aand�1862e nd theeRules andeRegulationsin dof Sans <br /> application <br /> Joaquin County Public Health Services. <br /> USr 9 City Lot size/Acreage <br /> Job Addlea y� <br /> a4 Phone <br /> Addres <br /> Owner's Name ,r <br /> �Q n a. 8 icense g --Phon <br /> Conlrac ddres�� 1 <br /> NEW WELL ❑ WELL REPLACEMENT (7 ; DESTRUCTION Ll out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring well 0 <br /> PUMP INSTALLATION es SYSTEM REPAIR <br /> SEWER LINES ---/DISPOSAL FLD.— PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK --. PITSISUMPS .� <br /> FOUNDATION ._ AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP>:CIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom © Manteca Dia. of Well Excavation <br /> M Industrial �-It Specifications <br /> C7 Tracy Type of Casing <br /> U Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> ublit I'1 Other ❑ Delta <br /> CI lrrigaiion Approx`Depth I] Eastern Surface 5euhlnsta4led by d <br /> ,,� H P mac. —,f State Work Dona W <br /> Repair Work Done L� fYPe of Pump Sealing Nsteiial i Deptr <br /> Well Destruction © Well Dismiter -, Fi11er,Mate>•lal i=Aepth ' Z`" <br /> Depth. �� system rmitted it ublic sewer is p,Q0 <br /> ii TYPE OF SEPTIC WORK: NEW INSMLATIOJ ' REFiAIRlAOOITION 1 DESTRUCTION G (No <br /> srwthin 200lest•1 p v; <br /> Installation will sem:.,ResiiienCe� �Cammercial, Other <br /> 1 Number of living units: NumberFof bedrooms A Water table depth <br /> Character of wil to a depth of 3 feet: No. Compartments <br /> C3SEPTIC TANK Type/Mfg Cbpat ity�.�— <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ _ <br /> # Property Lina <br /> Distance to nearest: Well Foundation..�.�— <br /> Total lengthlsixa <br /> LEACHING LINE 0 No. & Length of lines property Line <br /> FILTER BED Q Distance to nearest: Waif Foundation -�- <br /> 1 <br /> i Number <br /> SEEPAGE PITS it Depth Sire i property Line�-- <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS - 0 `� <br /> that the work will be done in eccardance with San Joaquin county ordinances, state laws, and <br /> Ihereby certify that I haus prepared this application and <br /> rules and regulations of the Sen Joaquin County <br /> re certifies the following':""I-cartify that in the performance of the work for which this permit is issued. I shall not <br /> Home owner or licensed agent's signatuecome subject to workman's compensation laws of Calilomia." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to b <br /> candies the following: 111 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." f <br /> The applicant must ca r all required petitions• Complete dr aXino on verse side. <br /> rids <br /> Data: <br /> Signed �( <br /> '. FOR DEPARTMENT USE ONLY 16*&Aes <br /> � � <br /> • Date <br /> Application Accepted by Nr <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Additional Comments. — <br /> Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT AEMrTTED '" CK RECEIVED BY DATE PERPAMNO. <br /> INFO NT Rt1E <br /> p�J 97- 'At 1z <br /> . EH 13.24 tREv.1/M61 A?P l T�- v V VGf <br /> EK 7436 <br />