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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (249)468-3420 <br /> P O BOR 2009, STOC&TON, CA 95201 <br /> EgP SES 1 Y:AR FROM DATE—ION—ED <br /> (Complete in Triplicate) in <br /> work <br /> Application is hereby made toSan xith in County <br /> for tpermit ditancenNo. 549struct and1862or sand the tall eRules and eRegulations dof Sans <br /> application is made in compliance4 �� _ 3 <br /> Joaquin County Public Health Services. 6C, P e- <br /> Ci <br /> City I [l. Size/Acreage <br /> t •3. <br /> Job Address I � <br /> Phone <br /> Owner's Name 1 Address 1 <br /> f Y -Address t • Q' License Noszi�Q3 —Phone ; <br /> Contractor DESTRUCTION Ll Out of Bervice Well ❑ <br /> TYPE Of WELL/PUMP'. NEW WELL WELL REPLACEMENT n ❑ <br /> Monitoring Well C❑ <br /> SYSTEM REPAIR D OTHER <br /> PUMP INSTALLATION PROP. LINE <br /> SEWER LINES �.--- DISPOSAL FLU. � J i <br /> DISTANCE TO NEAREST: SEPTIC TANK == PITS/SUMPS t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing a �� Specifications <br /> pomesticlPrivate ,°Gravel Pack ❑ Tracy e7,n,.n Tyne f rqut <br /> I'! Public � (:1 Other ❑ Delta Depth of Grout Seal <br /> _ l 3.11 u <br /> I i lrrigation� Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done C7 Type of Pump SF�� H.P. State Work Done_ <br /> Sealing Material & Depth <br /> Well Destruction ' ❑ Well Diameter Material & Deth <br /> _ Depth <br /> Filler Ma P <br /> TYPE-OF SEPTIC-WORK: ,NEW INSTALLATION I I. REPAIR/ADDITION l I DESTRUCTION i I al o sepablelw tsystem perm(sallied if public sewer is 1 <br /> j CIP <br /> Installation will serve:—Residence Commercial Other ^� <br /> 1 Number of.living units: Number of bedrooms <br /> f Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK "' ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> ' -- -, <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. &-Length_of lines,_S Total length/size <br /> j Property LineY <br /> I FILTER BED , .„; CI Distance to nearest: 4 Well Foundation P Y <br /> 4 <br /> SEEPAGE PITS I I DepthSiza Number <br /> SUMPS , L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> lk -' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, scala laws, and <br /> rules and regulations of the San Joaquin County <br /> i ,'}coma owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or subcontracting signature <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 /> I tion laws of California." <br /> !{ The applicant must call for all required inspections.-rtiomplete drawing on reverse side. <br /> Signed <br /> 11A At OnCs.40at <br /> Data: <br /> NT USE ONLY <br /> Date Area — <br /> Application Accepted by <br /> Pit orOspection by <br /> Final Inspection b��` Dates �1 v 1 <br /> 1 Additional Comments: <br /> I{ Applicant - Return all copies to: San Joaquin County Public Health ' <br /> y Services, Environmental Health Permit/Services �V" <br /> 111 __r 1601 E. Hazeltorf'Ave.',` P 0 Box 2009; Stockton, CA 95201 <br /> FEE KKRECEIVES) BY DATE PERMIT'NO. <br /> INFO AMOUNT OUE AMOUNT REMITTED <br /> EH 53-24 IREV,I/x 51 /675 OU <br /> EH 14.28 q0 <br />