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APPLICATION FOR PERMIT <br /> STT JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> } FR11` <br /> DTE S <br /> MIT FIRES 1 Y <br /> (Complete in Triplicate) <br /> Application is hereby made,to San-Joaquin County for a permit to construct and/or install the work herein described. This <br /> Joaquin County Ordinance No. 549 and 1862 end the Rules sad Regu <br /> lotions of San <br /> appliestion is made in complianceivith gat+ Joao JI <br /> Joaquin County Public Health S ry cee; Lot Size/Acreage <br /> t Job Address Phone <br /> r s <br /> 1* ' �. Address <br /> Owns;'ra Name cam— <br /> �" i . ��] License No.�Z Phone � l <br /> Address DESTRUCTION ❑ Out of Service Well ❑ <br /> Contract WELL REPLACEMENT L] Monitoring Well ❑ <br /> ELL/PUMP: j NEW WELL ❑ REPAIR C7 OTHER ❑ <br /> Y <br /> PE OF W SYSTEM R <br /> T <br /> PUMP {NSTALLATION O DISPOSAL FLD.�— PROP. LINE <br /> SEWER LINES �- -- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �---� AGRICULTURE WELL — OTHER WELL— <br /> FOUNDATION �-��� <br /> } <br /> INTENDED USE . TYPE OF WfLL PROBLEM A of SPECIFICATION pia. of Well Casing <br /> Dia. of Weil Excavation Specifications <br /> ❑ Open Bottom ❑ Tracy Type of Casing_ <br /> Cl Industrial [] Tracy <br /> M, C Doltlasticl Private ❑ Gravel Pack Type of Grout <br /> {1 Other n Delta Depth of Grout Seal <br /> I'1 Public <br /> I I YrriUaiion ApproxDapth l I Eastern �, Surface Seal Installed+Slate Work Dona <br /> R Type of Pump ��� H.P. <br /> Repair Work Done U r SealingMaterial-&-VkPth'` <br /> Well Destruction 0 Wall Diameter _ -- uer Material i Depth <br /> W Depth POM", it public Bawer is <br /> ., available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLLATION I 1 REPAIR ADDITION DESTRUCTION-al�l INo naptic system Po n <br /> N Other „1 <br /> Installation will serve: Residence--- Commercial <br /> Number Of living units: � Number of cams Water table depth " <br /> I Character of soil to a depth - $feat: No. Compartments <br /> Capacity__- <br /> SEPTIC TANK. 0 Typo/Mfg y ** •Method of Disposal Y <br /> ;1 <br /> PKG. TREATMENT PLY.❑ `' <br /> i { _ Foundation•"' Property Line�.--- !. <br /> Distance to nearest:- Well r <br /> Total_length/iiziI i <br /> "LEACHING LINE No. k Length of lines �. <br /> Foundation — Property Lins <br /> h FILTER BED ❑ Distance to nearest: Well -- .-. <br /> SEEPAGE PITSiFoundation Property"Lino <br /> � Depth I Size'—vl - t <br /> -II h O <br /> �� <br /> SUMPS Ll Distance to nearest: Well -"�-- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared tliis application and that the work will be done in accordance with�San Joaquin county Ordinances, suede laws, end <br /> r rubs and regulations of the San Joaquin County. <br /> Home owner or licensed agent's signature certifies the following; "I ce RV�thiliii the performance Of_the work for which this Dermic is issued. l mature <br /> employ any person in such anneal n thebacoina performance cof the work farwhichthis'perm t is issuedOf ,shall employ persons nia�;' Contractor's tsubj cring it o warktman`s compensa <br /> certifies the foNowinp - - f <br /> tion laws of California." <br /> The applicant t call for u'sd inspections. Complete drawing on`roverse d r <br /> - Date: <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY1. s^� <br /> M <br /> Data <br /> Arae <br /> I Application Accepted by -` Date <br /> pato final lnapectian by" <br /> Grout Inecti <br /> spon by <br /> a �- <br /> t � - <br /> a Additional Comments: " *- <br /> I s to: San Joaquin County Public Health Sirvices <br /> Applicant - Return all copie <br /> Environmental Health Permit/Services <br /> i <br /> 445 N San Joaquin,-.P 0 Sox 2009, Sticn�QA 95201 <br /> K RECEIVED BY DATE PERMIT'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> F INFO <br /> 149, <br /> EH 13-24 IREV.I w a <br /> EH 14de <br />