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I <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTALHEALTHDIVISION <br />p O BOX 2009, STOCKTON, CA 95201 y <br />209) 468-3447 k <br />1 <br />Complete in Triplicate) <br />vork <br />Application-is hereby 'Ldee,,tO San Vo hui CJ QuinQGounr a ty <br />Ordinancermit <br />to nNo <br />5k9ct <br />sandol862aand <br />thetall <br />eRules <br />eadeRegulationein <br />dof <br />Sana <br />application Is toad <br />CVS , <br />Joaquin County Public Health Services. <br />fffrwln <br />CityDl Lot Size/Acreage A <br />Jot) Address ' ` <br />f <br />74 <br />Phone -3 - <br />Address <br />Owner's Name. <br />GT License No. Phone <br />Contractor— ' - <br />Address y !417 <br />NEW WELL WELL REPLA....EMENT O1:STRUCTkON Out of Service titell L <br />TYPE OF WELLIPUMP: OTHER p Monitoring Well <br />PUMP INSTALLATION 13 <br />REPAIR <br />DISPOSAL FLD._ PROP. LINE <br />SEWER LINES . <br />PITS/SUMPSDISTANCETONEAREST: SEPTIC TANK --- <br />AGRICULTURE WELL OTHER WELL^-..-- <br />FOUNDATION ._J <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Casing v <br />jI O Opsn Bottom 0.MantecaofWell Excavation <br />71 Industrial Specifications <br />L7 Tracy Type of Casing <br />U Domestic/Private C) Greve] Pack <br />Depth of Grout Seal <br />Type of Grout <br />Cl PubiiC i'1 Other i Delta O <br />CI Irrsoation <br />Approx. Depth Eastern Surface Seal Installed State Work Done, <br />j <br />Repair Work Done U Type at Pump H.P. <br />Sealing Material & Depth LL <br />Well Destruction O Well Diameter} <br />Filler Material & Depth <br />Depth armitied <br />TYPE OF SEPTIC WORK: NEW INSTALLATION <br />tc system <br />REPAIRIADOITION _ DESTRUCTION CI aNailabPelw <br />thin 200 feet.) <br />it public sower is <br />Ott4le <br />installation will serve; Residenc ` Commercial Othere <br />Number of living units: L Number of bedrooms Water table depth <br />Character of soil to a depth of 3 feet: <br />r <br />No Compartments Z <br />SEPTIC TANK Type/Mfg Capacity <br />Method of Disposal <br />PKG. TREATMENT PLT. yS <br />Distance to neareif: Wel Foundation s <br />Property Line <br />Total length/size <br />LEACHING LINE C'1 No. a of lines <br />Property Line <br />FILTER BED is Distance to nares . Watt Foundation - <br />f <br />j 1 Size <br />Number <br />I SEEPAGE PITS l I Depth Property Line <br />SUMPS Lt Distance io nearest: Well Foundation <br />DISPOSAL PONDS 1 F <br />rk will be done in accordance with San Joaq`u,h county ordinances, state taws, anIherebycertifythatIhavepreparedthisapplicationandthatthewo <br />rules and regulations of the San Joaquin County <br />o4lowing, "I certify that in the performance of the work for which this permit is issued, I shall notHomeownerorlicensedagent's signature certifies the f <br />cervil <br />the <br />person in suchmannerman shat n the <br />come subjectbjecet <br />f the work <br />foto <br />swh cheth s permit <br />nsation tis issued, <br />s of <br />I shall employapersons fsubj ct t workman's compensa- <br />tion laws of California." <br />r <br />The applicant must call for all required inspections. Cc"to drawing on reverse e. <br />91 <br />LTitle: <br />4 <br />i <br />6/ <br />J Date: - <br />r Signed <br />FOR DEPARTMENT USE-ONLY <br />JlfDa <br />72'/ Area <br />f Application Accepted by 2 <br />Pit or Grout Inspection by Date Final Inspection by <br />Date <br />r <br />Additional Comments: <br />Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />445 N SAN JOAQUIN, P o BOX 2009, STOCKTON, CA 95201 <br />FEE <br />CK RECfiIVt2D 8Y DATE PERMIT'NO. <br />INFO <br />MOUNT DUE AMOUNT 9EMITTED CASH <br />EH 13.24 IREV. <br />EH?4.26