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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI.ON � . <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 w <br /> P 0 BOX 2009, STOCKTON, CA 95201 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> v1 / (Complete in Triplicate) ���-� •Rg� <br /> Application is hereby made•to San;Joaquin County for a permit to construct and/or install the work herein described. This - <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> yy r <br /> )(lob Address n 04M+�j� <br /> OWE• City Size/Acreage <br /> /owner's NameMMA SALAm � .. Address :5134 E 4929 "— Phone <br /> �Conlracto �� Address +6�A7 <br /> 4W.IL4icense No?9831i94 Phone"443--5` O.7. <br /> TYPE OF WELL/PUMP: NEW WE ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INST TION ❑ SYSTEM REP 0 OTHER ❑ Monitoring Well ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK S R LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRIC ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE EA C-OkSTRUCTION SPECIFICATIONS 0 <br /> M Industrial ❑ Open Bottom anteca Dia. of Excavation Dia. of Well Casing <br /> -1 Domestic/Private r ❑ Gravel Pack l7 Tracy Type of Casing. Specifications rr� <br /> I"I PublicL�Zrox. <br /> C-1Delta Depth of Grout Seal Type of GroutII Irrigation Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done _ M <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> _ Death Filler Matri <br /> yeal & Depth + <br /> TYPE OF,SEPTIC WORK; NEW INSTALLATION t 14REP.AIRIADDITION-I•I,,D.ESTRUCTIO No septic system permitted if public sewer is <br /> —.-1 + vailable within 200 feet-1 i <br /> T_ :,.7--- .. . � . <br /> Installation will serve: Residence Commercial` Other t <br /> Number+of living units:. - , Number of bedrooms <br /> Character of soil to a deptWgf 31eet: '; - Water table depth <br /> SEPTIC TANK. © Type7Mf'g� t Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl r ;'Method of Disposal <br /> I Distance to nearest: well Foundation Property Line <br /> ^.Y <br /> LEACHING LINE'..}` t Jb ,i,No f9 Lerigth=of tines" Total length/size <br /> FILTER BED O Distance to nearest:----Well-=-- Foundation -Properly Line t <br /> SEEPAGE PITS 11 Depth Size Number ± I <br /> SUMPS LI Distance to nearest: Well Foundation Property line _ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done irraccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin;County :.s� ) '1� <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 no�6i <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ContractoIr's hiring or sub-contracting signature.,tr,r <br /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employpersons subject to workman's compensa r <br /> tion laws of California." <br /> The app lica st call or all uir inspections. Complete drawing on reverse side. <br /> &�oA�e ar2s�9z <br /> Signed X Title: Date: <br /> a i 7 <br /> R DEPARTMENT USE ONLY a �p d, <br /> Application Accepted by �L�Ciw.. ,,,,, Dates 1�'�[� 'l 2— Area Z ' <br /> Pit or Grout inspection bye Date Final Inspection by Date <br /> Additional Comments: <br /> Appli=cant'-'Return'All copies to: San-Joaquin 'County'Ptiblic Health•Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P .0 Box 2009, Stkn, CA 95201r <br /> FEE AMOUNT DUE AMOVN7 REMITTED- • "'CK �` RECEIVED'BV ­ DATE PERM17'ND. <br /> IEEENFO CASH <br /> . EH1316 iREV.1iK51 C' <br /> EH t42s �.? <br />