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• <br /> p APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES G2 � <br /> (4 ENVIRONMENTAL HEALTH DIVISION l <br /> "( 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> a <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1, "AR FM DTE ISSUIM <br /> (Complete in Triplicate) k <br /> Application is hereby made to Ban Joaquin county for a permit to construct and/or install the vork herein deacrib f Sans ' <br /> application is made in cost1'1ance with San Joaquin county Ordinance"No. 549 and 1862 and the Rules and Regula <br /> Joaquin county Public Healt�hservices. <br /> Job Address <br /> /seas G/ City //� Lot Size/Acreage <br /> rSLC.(. Phone <br /> Owner's Name P +� a Address <br /> 1N ,C /4( License No:��-Phone <br /> Contrattor Address <br /> NEW WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> WELL <br /> TYPE OF WELL/PUMP: Monitoring Well [] <br /> �� r i <br /> PUMP�INSTA LLATION ❑ <br /> SYSTEM REPAIR 11 OTHER ❑ <br /> ��' SEWER LINES DISPOSAL FLD.�'t'PROf. LINE <br /> DISTANCE TO NEAREST: SEPTIiC TANK_„f — PITS/SUMPSY z--­ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL �- <br /> II <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L, Industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation <br /> Graaf Pack Type of Casing_. ✓� Specifications <br /> Domestic/Private �l Tracy Depth of Grout Seal �Typa of Grout <br /> Public Otfiker n Delta <br /> liriation �S��Approx. Depth I I Eastern Surface Seal Installed by h r <br /> f Pump ��- H•P <br /> U o <br /> State Work Oona_ <br /> Repair Work Done Type 1 Depth <br /> Sealing Material i <br /> Well Destruction ❑ Well Diameter <br /> Dapi Tiller Materiel i Depth <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION I V <br /> REPAIR/ADDITION I i DESTRUCTION i I avail blelw thin 200 feetstem .) d public saver is <br /> {I!IS 1 <br /> Installation will serve: Reside ince Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of sad to a depth of,3 fest: No. Compartments <br /> SEPTIC TANK O Type/Mfg Capacity <br /> Method of Disposal <br /> PKC. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Wall FoundatioProperty <br /> jTotal length/size <br /> k LEACHING LINE C1 N��. m Length of lines Property Lina <br /> FILTER BED O Distance to nearest: Well Foundation <br /> SEEPAGE PITS it I th Size Number <br /> LI Distance to nearest: Well Foundation Property Line <br /> SUMPS. p <br /> DISPOSAL PONDS ❑ 1I <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, and <br /> rules and regulation$of the San Joaquin county <br /> Horne owner or licensed agent' -Signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> F certifies tfle foNowing: "1 cer[ify Chit in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campansa <br /> tion laws of Calif nils." <br /> I The appy t rnu t call for all Luil i tions. Complete"drawing on rev se side. <br /> • ' J Data: •-- <br /> Signed 1 Tide: <br /> FO DEP RT ENT USE ONLY r <br /> JData Area <br /> Application Accepted by 9 <br /> I Ph or rout I tion by <br /> I: Date_ _-- Final Inspection b Date <br /> Additional Comments: - <br /> r <br /> Applicant - Return all copies to:, San Joaquin County Public Health Services `ju <br /> Environmental Health Permit/Services L <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 85201 <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT' <br /> F AMONO. <br /> r INFO CASH <br /> a EM13.24111111/0151 w1v Q�r Qf � 3s7� �a—j]�'L qZ—�q5$' • <br /> Q��y � L` <br /> em 14-11111 l! [ <br />