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APPLICATION F'OR PERMIT <br /> SAN J"OAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 P+0 BOXHAZETON 009, S� PHONE CKTON, CA0 ^5420 <br /> 952011 <br /> PEEXP RES 1 YEAR <br /> "Complete in Triplicate) <br /> escribed. <br /> Applicatioe is hereby made.to San <br /> nce Joaquin <br /> with County <br /> dr a County OrditasncenNo. 549costructaa 1 1862s <br /> end theeRules and Regulationeof Sana <br /> application s made n ccmtp <br /> Joaquin County Public Health Services. . 1? ,,LOt <br /> d Ci;y /�• <br /> �f Size;;crettge �1J ''ham <br /> Job Address <br /> G� '�'���ClJ1� � � <br /> Phone <br /> Address <br /> Owner's Name . <br /> License No. gone <br /> Contractor__J # Address —' <br /> Out of Servic <br /> DESTRUCTION G e Well Q <br /> TYPE OF WELL;PUMP. NEW WELL ❑ WELL REPLACEMENT :] Monitoring well [� <br /> SYSTEM REPAIR �! OTHER <br /> PUMP INSTALLATION D DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- <br /> -------- AGRICULTURE WELL OTHER WELL PITS/SLUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom U Manteca Dia. of Well Excavation <br /> Type of Casin Specificat,on5 <br /> T <br /> FI Domestic?Private Ll Gravel Pack D Tracy yf g— Type of Grout <br /> i Public <br /> I'! Other Cl Delta Depth of Grout Seal <br /> Approx. Depth 1 i Eastern <br /> Surface Seat Installed by <br /> I <br /> Irrigation State Work Done <br /> Repair Work Done G Type of Pump H.P. <br /> Seali=ng Material & Depth <br /> Well Destruction D Well Diameter <br /> Filler Material & Depth <br /> Depth J— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRtAODITION ! DES7R'UCTION i ' availabierwithin 200 feetc system tled i! public sewer is <br /> Installation will serve: Residence __ Commercial — Other <br /> Number of living units: Number of bedrooms Watar table depth <br /> Character of soil 10 a depth of 3 feet: No. Compaitments - <br /> SEPTIC TANK D Type/M#g Capacity <br /> Method of Disposal I <br /> PKG. TREATMENT PLT.C1, <br /> Property Line <br /> f Distance to nearest: Well Foundation <br /> ° d <br /> ___ Total length/size. <br /> LEACHING LINE L No. & Length cf Eines —� Prope;rty Lina <br /> FILTER BED F Distance t arest; Well F undation <br /> ESire Numbaf ------- <br /> SEEPAGE PITS i I Depth <br /> SUMPS Property Line <br /> I ' E; Distance to nearest: Well Foundation <br /> f DISPOSAL PONDS ❑ <br /> `f I hereby comity that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ru{as and regulations of the San Joaquin County <br /> Nome owner l licensed agent's signature cenidies the following: "I certify that in the p©rtormance pf the work for which this permit!s issued, !signature <br /> shah not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Cantracter3ons snng 0?subub ect to workman-contract'sgcOm ansa <br /> certifies the following: "'I Certty that in the performance of the work for which this permit is issued, !shell employ p 1 <br /> tion laws of California." <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> J G%��• Signed X � Title:._ U` '��� Date: <br /> FO"EPART T USE ONLY <br /> �'�`�'� '4_ A. a- •�', <br /> i ApplicationDate <br /> Accepted by <br /> ! Pit or Grout Inspection by Date Final Insp <br /> action by <br /> Addltiona!Comments: <br /> y ' <br /> Applicant – Aeturn all copies to: San Joaquin County Public Health <br /> Services, Enviroruaental Health Permit/Services <br /> I 1401 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED `ASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 13.•24 tilEV. �a9� <br /> EH 14.26 <br />