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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES� � " r ' <br /> I ENVIRONMENTAL HEALTH DIVISION ®w`L 2 7 ii`ffl <br /> p O BOX 2009, STOCKTON, CA 95201 ENVIRON NA TAL H Al�Ti� <br /> (209) 468-344? PERi�tIT/SERV iC S <br /> ISSUED <br /> }� (Complete in Triplicate) <br /> in <br /> Application is hereby made t0 Sam Joaquin CJooaaquinoC ape ordinanceto nstruct No. 549Bandor install 1862 and thee voik Rules andeRegulationsdof Sans <br /> application is raade in ,cw�liance,with San 4 ! <br /> Joaquin County Public Health services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone V <br /> Address <br /> Owner's Name r <br /> License No. Phana <br /> �ctor DESTRUCTION ❑ out of Service Well ❑ <br /> TYPE OF WELL/PUMP• NEW WE L C] WELL REPLACE NT C 1 Monitoring Well C7 <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> • f DISPOSAL FLD. -PROP. LINE <br /> SEWER LINES �-- ,/ <br /> DISTANCE TO NEAREST: SEPTIC TANK S <br /> — AGRICULTURE WELL OTHER WELL <br /> PITS/SUMP <br /> FOUNDATION <br /> _ S . <br /> _- — TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE — pie. of Well Excavation <br /> C� Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> Type of Casing <br /> ameaticlPrivate ❑ Gravel Pack. ❑ Tracy Depth of Grout Seal Type of Grout <br /> i:l Other ❑ De1ta <br /> MPublic Surlace Seal Installed by <br /> CJ IrriUation Approx.�Dep h E tern <br /> i H.P a s or en <br /> Repair Work Done V Type of Pump ___�.,--- Sealing Hsterlal*fir Depth <br /> Weil Destruction ❑ Well Diameter �� <br /> Depth Filler Materiel-Ilr'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIAODITION Cly D.EST,AUCl <br /> rION.�I availablew within lest-1(milled ifpublic sewer is <br /> Installation will serve: .. Residence Commercial Other' <br /> Number of living units: Number of bedrooms- y <br /> Water table depth 'v <br /> Character of soil to a depth of 3 feet:} Capacity — No. Compartments <br /> SEPTIC TANK: ❑ - Type/Mfp <br /> Method of Disposal <br /> PKG. TREATMENT PLT.Cl 1' Property Line <br /> Distance:to nearest: Well Foundation��--- <br /> Total length/size � <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> { FILTER BED n Distance to nearest: Walt Foundation Pe Y <br /> ,l <br /> SEEPAGE PITS I I Depth <br /> (I Size Number <br /> l SUMPS LI Distance -- Property Line <br /> to nearest: Well Foundation <br /> — <br /> DISPOSAL PONDS ❑ <br /> - �I tieteliy`certify That l have prepared•lhii applicaiion 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 ar licensed agent's signature certifies the following_T"1 certify that in the performance of the work_for which this permit is issued, I shall not <br /> employ any person in euch'mArinsi as to bec"s eubjact to workman's compensation laws of California,",Contractor's hiring or sub-contracliiigsinpens e r <br /> certifies the following: "I certify that in{he performance of the work for which this permit is issued•,I shall employ persons subject to workman's oorrtpensa <br /> tion laws of California." <br /> f The applican st•call for equired inspgctions. Complete drawing an rev side. <br /> Title:, <br /> Date: <br /> Signe <br /> FOR DEPARTMENT USE ONL <br /> � CorDate / Area ;2.f <br /> Application Accepted by <br /> Pit or Grout Inspection by Date — <br /> Final Inspection by ' Date Z <br /> Additional Comments: <br /> T <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN- P O BOX 2008, STOCKTON. CA 86201 <br /> CKgECEIVED BY ATE PERMII'NO, <br /> FEE AMOUNT DUE AMOUNT fiEMITTED CASH <br /> INFO <br /> . EH 13-24 IIIEV,ti n B) <br /> i m A-2e <br />