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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ��► <br /> ` ENTAL HEALTH DIVISION <br /> W AVE.., PHONE (209)468-3420 <br /> 09, STOCKTON, CA 95201 <br /> / UR IG 1991 <br /> iS 1 .YEAR FROM DATE ISSN <br /> (, Letein Triplicate) EN`:;�,=`NIN!j"NTALHHEAL,Appl: t to construct and/or install the work hi��ilhyt&esribed.�SThis <br /> appZ: dinance No. 549 and 1862 and the Rules and Regulations of'San <br /> Joagi <br /> ,�iJob? City S l Lot Size/Acreage <br /> 4 Owns <br /> Cont, O C&-License No. Phone <br /> TYPE ;WELL REPLACEMENT Cl DESTRUCTION Li Out of Service Kell C1 <br /> SYSTEM REPAIR ❑ OTHER Cl Monitoring Well 1� <br /> DIST, LINES L DISPOSAL FLO. - PROP, LINE <br /> JLTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavationnn Dia. of Well Casing -Z- <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �w_ __--__ Specifications ✓" <br /> I'I Public fiA Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 4&2�Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 'O Type/Mfg Capacity No. Compartments s\ <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total iength/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Some owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the follow' "1 certify that in the performance of the'work for which this permit is issued, I shall employ persons subject to workman's compensa• 1 <br /> tion laws of Cal' rni <br /> The applican ust all for all re ;Hsps, ti S. Complete drawing overse side, M <br /> Signed X /L{j' G Title: � �1 —�L� %1�-- <br /> Date: <br /> ti t <br /> FOR DEPARTMENT USE ONLY <br /> j ! <br /> Application Accepted by Date' `' Area4' '�! <br /> Pit or Grout Inspection by L 'l Data�� Z r Final Inspection by Date Z a <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, &vironmental Health Pertait/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, :CA 95201FEE 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY A7E PERM17'NO. <br /> • EH^'.H[pEv. WM tin>> ,0-0 5�'�"�- �r <br />