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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE '(209)468-3420 <br /> ,I <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IE (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. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address r 3-741 S �(' _ CityPll<!�, Lot Size/Acreage <br /> Owner's Name Miss Phone <br /> W I <br /> Contractor_ -_f_x"LeAddress�S� V ti-License No.�q3Il8 Phone 52`�'�e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> f .. <br /> FOUNDATION * --A AGRICU,LT_URE WELL7HER WELL PITS/SUMPS <br /> f INTENDED USE -TYPE OF WELL FfR-66'-L EM AREA CONSTRUCTION'SPECIFICATIONS <br /> i U) Industrial--El Open Bottom, _0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 <br /> Domestic/Private ❑ Gravel Pack C..Tracy � Type of Casing_ Specifications <br /> f"I Public CI Other F- Delta `1 Depth of Grout Seal Type of Grout <br /> r I i Irrigation _ Approx.E Depth I } Eastern "Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction Ca Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION=00—REPAIR/ADDITION i I DESTRUCTION I I fNo septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence V Commercial_ ther s <br /> Number of living units: __J_,L Numlier of be oms _ <br /> Character of soil to a depot of 3 feet:` Q Water table depth <br /> SEPTIC TANK ❑ Type/Mfg'�: Y Ciipacfty� 00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ k ! ! Method of Dispotal <br /> e <br /> Distance to nearest: well 110Z) <br /> e Foundation—�»b Property Liner_s6 r <br /> LEACHING LINE` Nd.-&-bangth of lines Y_Total length/size <br /> FILTER BED J€ ❑ Distance to nearest: Well fro Foundation�1 _ Property Line." <br /> -SEEPAGE PITS I I Depth 'I Size Number I d <br /> SUMPS LI Distance to nearest: Well Feundatio Property tinee <br /> DISPOSAL PONDS ❑! <br /> 1 hereby certify that I have prepared this,application 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 { 1 E ' <br /> -owner-or-licensed- <br /> Homeagenewitignature certifes_ a following;�I certify thatsin the performance of the work for which this permit is issued, I shall not <br /> employ.any person in such manner as to^becomes ject to workman's compensation;laws of California. Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the parlor ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." Tr <br /> i 1 <br /> The applican for all requi inspec b . Complete drawing on reverse side. i <br /> • 21 �iZ <br /> Signed X Title: • Date: ! <br /> i F DEP NLY i <br /> Application Accepted by r I Date res "�.� <br /> Pit or Grout Inspection by ate in/al�lspectior1i/b Oat <br /> Additional Comments: <br /> Applicant - Returti all copies to: San Joaquin County, Public Health Services <br /> Environmental Health.Permit/Services <br /> _ 445-.1'I.-San-Joaqui•n;-P•-o=-Bax 2009,Stkn;-CA-•95201 <br /> <.� FEEAMO 'DUE AMOUNT REMITTED JECEIVED BY DATE PERMIT'NO. <br /> IN <br /> f/-EH 2i / �� I <br /> " /(REV. x 51 <br /> EH 1 F <br />