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APPLICATION FOR PERMIT <br /> SAN OAQUIN � 1n <br /> COUNTY PUBLIC HEALTH SERVICES . + <br /> DIVISION U <br /> ENVIRONMENTAL HEALTH ON209)468-3420 <br /> 445 N SAN JOAQUIN, CA 95201 <br /> P O BOX 2009, STO(:STON, <br /> p IT EXPIRES 1 Y <br /> FROM D ATUED. <br /> (Complete in Triplicate} <br /> Joaquin county for a permit to construct and/or install the work herein ulationsd. This <br /> i Ordinance No. 51+4 and 1862 and the Rules and Rsguystione of San <br /> Application is hereby made.to San' 064 <br /> application is made in compliance ixith San Joaquin County OC <br /> Joaquin County Public Health Services, City Lot Size/Acreage <br /> Job Address / y(,� Phone <br /> d <br /> ress O <br /> Owner's Name C �_ �` _L <br /> g r License No A Pho e <br /> ddress pESTRUCTION 0 put of Service well ❑ <br /> Contractor WELL REPLACEMENT ❑ Monitoring Well ❑ <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD.� <br /> SEWER LINES OTHER WELL PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL <br /> FOUNDATION <br /> tp INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Ois. of Well Casing <br /> f p-Open-fiottom - C) Manteca Dia. of Well Excavation specifications <br /> l Cl Industrial C) Tracy Type of Casing_ Type of Grout <br /> Cl DomastiCIPflvete El Gravel Peck <br /> ['I Public Cl Other <br /> + fl Delta Depth of Grout Seal O <br /> Surface Saul installed try <br /> I I Irrigation � Approx. Depth 1 l Eastern Stats Work Don* <br /> of Pump ,---- H.P. <br /> Repair Work Done L3 Type Sealing Material i Depth ^ <br /> Wail Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> r vailable within 200 feet.) <br /> PE OF SEPTIC WORK: NEW INSTALLATION l,l REPAIRIADDITION I i DESTRUCTION lNo septic system permitted it public sewer 1s <br /> will sb <br /> de� Commercial_ Other <br /> Installation _ <br /> Number of living units: r of bedrooms of table depth <br /> Character of sop to a depth of 3 fiat: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> � PKC. TREATMENT PLT. ❑ t ndation Property Line�—• <br /> Distance to nearest: Wel <br /> otal length/sr <br /> LEACHING LINE Ll No. & Lerigth of lines <br /> T <br /> FILTER BED 0Distance to at: Well <br /> Foundation Property Line <br /> th; Sipa Number <br /> SEEPAGE PITS Foundation Property Line <br /> — <br /> SUMPS Ll Distance to nearest: Well <br /> t DISPOS ONDS ❑ <br /> retry certify that I hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> the following: "I certify that in the performance of the work for which this permit is issued, 1 shell not <br /> Home owner or licensed agent's signature certifies <br /> i employ any parson in such manner as to bacons subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> i <br /> e of the work for which this permit is issued, I shall employ persons subject to workma <br /> sa- <br /> certifies the following: "1 certify that in the performancn s compan <br /> tion laws of California." , <br /> The applicant mus cal for all required inspections. Complete drawing an reverse side. <br /> Date: Z <br /> /,'signed Title: <br /> OR DEPARTMENT USE ONLY „Z <br /> Date 2_ Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Data- ,.�.—.�- <br /> Final In by Data <br /> Additional Comments: <br /> Applicant - Saturn all copies to: EnvironmentalJoaquin oun <br /> Health Permit/servicesvices <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK RECEIVED By DATE PERMIT•NO. <br /> INFO <br /> . EH 1344 IHEV.1/ri sf <br /> EH 14-2e <br />