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APPLICATION FOR PERM I T <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENNTAL HEALTH DIVISION <br /> 445 N SAN .IOAQIIIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> l <br /> PERMIT MIRE5 1 YkR FR �M DATE INUERD <br /> �! (Complete in Triplicate) <br /> ThiApplication is hereby made,to Sen Joaquin countquin°County Ordinancermit to nHo 549struct e o1662sand thetall elftslea andvork eRegulationin sdof Sana <br /> application in made in compliance <br /> Joaquin County Public Heath Services. )0, <br /> SD City Lot Size/Acreage <br /> Job Address <br /> .I, <br /> S q Phone 2 <br /> Address <br /> Owner's Name — <br /> onttactar Address <br /> P --� cerise Phone <br /> se No. -- <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Vel1 ❑ <br /> TY OF WELL/PUMP: OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,. <br /> SEWER LINES �.�-- DISPOSAL,FLD� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 0THER WELL PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing. <br /> C7 Industrial ❑ Open Bottom <br /> E3 Manteca Dia. of Well Excavation Specifications.. - <br /> C] Domestic/Private ❑ Gr"#!Peck C] Tracy Type of Casing_ �- <br /> f fl Delta Depth of Grout Seal _ Type of Grout <br /> {'1 Public Cl Other � <br /> k i I Irrigation 0! Approx, Depth I I Eastern. Surface Saul Installed by <br /> H P State Work Done <br /> Repair Work Done: U Type of Pump Sealing Material A Depth <br /> Well Destruction ❑ Weil DiameterrFiller Mate al i Depth <br /> �' Depth N <br /> TYPE OF SEPTIC.'WORK: NEW INSTALLATION I I REPAIR/ADDtTIO DESTRUCTION I I afvailabs within 200 feetd septic System .) �f public sewer is <br /> Installation wilt sans: Residence— Commercial :Other <br /> Number of living units: Number of becir r <br /> r Chuscter of soil to a dspth�of 3 feet: `-a'-1%,A s Water table depth <br /> SEPTIC TANK ❑ Type/Mig Capacity �sNo,--Compartments <br /> Method of Disposal <br /> I PKG. TREATMENT PLT.❑ I�. i I , <br /> �:Distance to nearest: Well �Foundation.y Property Line <br /> LEACHING LINE Cl !-!No. b Length of lines <br /> i Total length/size <br /> FILTER BED 1- ❑ ilDistance to nearest: Well ��' y 1'Foundation Property Lina <br /> i y <br /> r ` ?I. ' Size t Number <br /> SEEPAGE PITS I I y Depth <br /> i. SUMPS LI ';i Distance to nerarast: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ,; - <br /> I hereby certify that.l have 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 /> Home 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 /> 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 following: "I certify that in the performance of the work for which this pdrmit is issued, I shalt-employfperaons subject to workman's compensa- <br /> tion laws of California."The applica!Accepte" <br /> {I for all�, —�incu�o� uom�srawing verse side. , <br /> � ;!. Date: f 0 �• <br /> ign Title: A <br /> �S <br /> F DEPAR MENT USE ONLY <br /> I. ; �`� � ArseApplic nby ! -Date <br /> - II ! r � Dat\. ; <br /> I Ph or Grout Inspection by _ Date t Final Inspection b <br /> Additional Comments: <br /> Applicant - Returnfall copies to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> x..445•N,San Joaquin-,_-P•-O Box-2005, Stkn, CA 95201 <br /> FEE AMOUNT OtJE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH t3.24(REV.I,Its l �• ��, t 0� �` / �/`�� <br /> EM 14-26 <br /> ti <br /> 0 -_ <br />