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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 E%PIRES 1 YEAR FROM DATE ISSUED <br /> ;i (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct No. ck aando1862 and thnstall e Rules anwork deReBul�ations dof Sans <br /> application is made in compliance with San Joaquin county ordinance No. 5 9 <br /> Joaquin County Public.Hea,1th Service .' ) }} <br /> City ti! Lot Size/Acreage <br /> Job Address � <br /> ] G <br /> E Phone a� <br /> Address <br /> s Owner's Name } Q 93 <br /> Contractor Address <br /> License No. �5 Phone t`� 4 <br /> NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Gl Out of Service Well Gl <br /> TYPE OF WELLIPUMP: OTHER D Mtonirtoring Well �� <br /> PUMP INSTALLATION ❑ I SYSTEM REPAIR <br /> i l DISPOSAL FLD. PROP. LINE�1 <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES Pf75l5UMPS <br /> c mk <br /> FOU1.NDATION AGRICU_LTURE WELL: __ OTHER WELL— <br />` } INTENDED USE TYPE OF WELL PROBLEM AREA AL CONSTRUCT ION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Cl Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications i1 <br /> re <br /> �Domestic!Private ❑ Gravel Pack C7 Tracy iT YP of Casing- Type of Grout��� \\\ <br /> 11acsPublic I:1 Other nDelta +Depth of Grout Seal i. <br /> i I Irrigation Approx. Depth 14 Eastern SurfSeal Installed by <br /> nn State Work Done ? I- ' <br /> Repair Work Done U Type of Pump � H.P. ' <br /> 11 Sealing Material 5 Depth <br /> " Well Destruction 0 Well Diameter ___t <br /> c Depth Filler Material i Depth <br /> I. f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ I 1 DESTRUCTION i I septic system <br /> thin 200 feetrt;ed if8public sewer is <br /> t Installation will serve: Residence Commercial Other <br /> i Number of living units: w Number of bedrooms <br /> Water table depth <br /> Character of coil to a depth of 3 feet: t I ho-Compartmeints <br /> SEPTIC TANK' ❑ Type/Mfg Capacity-7-7-7- <br /> y fAethod;of,Disposal <br /> E PKG. TREATMENT PLT. ❑ I i <br /> {,r ,.F.oundatian Property Line <br /> Distance to ne�ares`t: c , <br /> f Total langth/sixeY <br /> LEACHING LINE ❑ No. & Length of,lines ' <br /> Foundation Property Line <br /> FILTER BED n Distance to near : • Well j <br /> - <br /> ' Site ! ' Number <br /> SEEPAGE PITS I I Depth Property Line <br /> 5UMPS Cl Distance to nearest: Weil ,«i Foundation <br /> _ �� �= , <br /> - ' <br /> ;- - -, _ � <br /> � ""DISPOSAL PONDS'°'�'C7"�'�` - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin c6unty ordm minces,state laws, and <br /> rules and regulations of the San Joaquin County }. , certify <br /> -t F <br /> ' Home"oiivnar*r,.l' erased agent's signature Certifies the following: "i certify that in the performance of the work for which tfiis:per I�it is issued, I shall not <br /> eFmpioy any so <br /> such manner as to become subject to workman's compensation laws of California."Contractors hiring of su4`'contracting signature <br /> T is issued, I shall employ persons subject toiworkman's compensa <br /> certifies the f lowr • "I certify that in the performance of the work for which this permit <br /> i tion le of rnla:" <br /> r The ap 'ca st call for all r uifed ins ti ns. Complete drawing on ev r side. 4 <br /> :E Title:) Qnr� Date: <br /> Signed <br /> - -- "' <br /> FO-08 DEP RIME USE ONLY <br /> �3o <br /> Date Area <br /> Application Accepted by <br /> 13 Date <br /> Pit or Grout Inspection'by Date FinalInspectby I� <br /> i <br /> Additional Comrnents: i <br /> Applicant - Return all copies-to— San Joaquin County Public Health Services <br /> Environmental Health Permit/Services i <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE t:K RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH <br /> . EH 53.441AEY. <br /> EH 1436 <br />