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" � ''' •- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Citydot Size/Acreage <br /> YJob Address /1 /b <br /> xID <br /> Owner's Name <br /> Address ` ► �� l— �r �Q V�— Phone ` <br /> g s2es <br /> Contractor Address License No, Phone <br /> TYPE OF WELLIPUMP: NEW WE ❑ WELL REPLACEMENT .. DESTRUCTION ❑ Out Monitoring Well <br /> f service Well 0 <br /> PUMP INSTALLATION SYSTE AIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A C URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBAREA ONSTRUCTiON SPECIFICATIONS O <br /> n Industrial E) Open Bottom Manteca Dia. o II Excavation Dia, of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing - Specifications r <br /> I'! Public (.1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ApProx. Depth 11 Eastern Surface Seal Installed by <br /> t Repair Work Done U Type of Pump H.P. State Work Done , <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION, aNtseptic <br /> system <br /> eastitled it public sewer is <br /> ailabe <br /> Installation will serve: Re 'deuce h Commercial— Other 1 <br /> Number of living units: Number of bedrooms__—1% <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg p it No. Compartments <br /> IVIPKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest, Well ,q�ypd�jpp,lrnrl �aperty Line <br /> i LEACHING LINE Cl No. & Length of linesle <br /> e l���N1 Or �� erg !size <br /> FILTER BED F) Distance to nearest: We ' l operty Lute <br /> �j f=. <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and <br /> t 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant trust call for all eq in 6tions. Complete drawing on reverse side. 9 <br /> Signed X Aw Title: Dater r�'• <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date • Area ll <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additions[ Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O 130 , Stkn, CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK EC IVSD BY DATE PERMIT'NO. <br /> INFO ///, //����CAAS��H�� y� �y q,2,- <br /> . EH 13.2 iREV.1/0151 7 �� 7�•C� lTstrT ✓•1- l� 1bf!cl <br /> 3 EH 14.25 // - _ <br /> d- <br />