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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q� <br /> ENVIRONMENTAL HEALTH DIVISION c <br /> 445 N SAN JOAQUIN, PHONE <br /> STOCKTON{2CA}9520I.420 / <br /> P O BOX 2009, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) _ <br /> tall ework herein s <br /> Grade, an vithuSanCJ Joaquin countyr a Ordinance diNo. 549and1862 <br /> rconstruct <br /> and/or <br /> ins <br /> Application is hereby and theRules and Regulations of San <br /> .application is made in compliance <br /> Joaquin county Public Health Services. <br /> y City Lot Size/Acreage <br /> xJob Address r �, <br /> Phone <br /> address <br /> 4 X Owner's Name <br /> I License tvo.,���Phone <br /> Contractor Address.��-- <br /> TYPE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT ❑ I, DESTRUCTION Cl Out of Service Well L <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ <br /> OTHER O Monitoring Well <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES . —- <br /> FOUNDATION AGRICULTURE WELL _. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA "'CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> CI Industrial <br /> C3 Open Bottom Manteca Dia. of Well Excavation <br /> C] Tracy Type of Casing= Specifications <br /> C:1 Domestic/Private ❑ Gravel Pack Dep <br /> of Grout Sea. t----r Type of Grout [j <br /> 1'1 Public 1:1 Other n Delta <br /> tern Surface Seal Instalied by <br /> } Irrigation Approx. Depth I I Easy� <br /> H R — State Work Done <br /> Repair Work Done 0 Type of Pump Scaling Material & Depth - <br /> Well Destruction ❑ Well Diameter Filler Materiall& Depth <br /> Depth <br /> PE OF SEPTIC WORK: NEW INSTALLATIONe <br /> 1 I /REPAIR/ADDITION I I DESTRUCTION t vailabtrwi within 20c system 0 feet, ii sewer is <br /> i <br /> Installation wt e: Residence! Commercial Other <br /> Number of living units: Number of bedrooms f ` <br /> a r< r.. Water table depth <br /> Character of soil to a depth of 3 fee . No. Compartments <br /> SEPTIC TANK ❑' Type/Mfg Capa <br /> Method of Disposal , <br /> PKG. TREATMENT PLT.❑ Property Line <br /> Distance to nearest: Well fou n <br /> f I' Total Is size <br /> LEACHING LINE ❑ No. & Length o Pro rt <br /> FILTER BED ❑ Distance earest: Weil Foundation pe y <br /> SEEPAGE PITS Depth 1` Size Number <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> DIS P 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 Iaws, and f <br /> rules and regulations Of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall not <br /> t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> I certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> II tion laws of California.,, <br /> The applic nt must tail for all req d ins lions ly�/"ta d�}�n (averse side. <br /> � t �� <br /> �y �►L� LT�itle: �lJy`J", Date: <br /> �igned . <br /> FOR DEPARTMENT uSE ONLY <br /> Date 91 Area <br /> Application Accepted by <br /> Pit or Grout Inspection <br /> f7!� Date Final Inspection by Date <br /> 3 Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA <br /> RECEIVED BY DA E PERMIT NO. <br /> INFO <br /> DEH 13-24(REV.Ii Rei ' <br /> EH 1426 <br />