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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 /> i PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> f (Complete in Triplicate) <br /> Application in 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 -SZ160,( I— -RD City 27GftPLot Size/Acreage <br /> Owner's Name 'Tas Address Phone <br /> Contractor A L0-00 �PW'v7— as <br /> ddress License No.,..qm9a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well 0 <br /> PUMP INSTALLATION ❑ 4' SYSTEM REPAIR OTHER ❑ Monitoring Nell <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE e <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> f:} Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications <br /> ['I Public El Other F1 Delta Depth of Grout Seal Type of Grout <br /> 1 rrigation _Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump �eH•P. State Work Done ¢ <br /> Well Destruction_O Well Diameter i Sealing.Material & Depth C <br /> Depth � Filler Material &`Aepth' <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I.I REPAIR/ADDITION I 1 DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other (� <br /> Number of living units: Number of bedrooms ,,✓, S <br /> Character of soil to a depth of 3 feet: # Water table depth kSEPTIC TANK ❑ Type/Mfg .-Capacity No. Compartments - <br /> PKG. TREATMENT PLT. ❑ o <br /> Method of Disposal � <br /> a Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearesi • Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL F'DNDS ­❑ <br /> I hereby certify that I have prepared this application and that the work willbe done'in accordance with San Joaquin county ordinances, state laws, ind <br /> rules and regulations of the San Joaquin County .., + I <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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant to ntcall for all required inspectionsomplete drawing on reverse 'de. <br /> Signed X- s �r] <br /> Title: Date: �7 <br /> . FOR CIEPARTfNENT USE ONLY <br /> Application Accepted by Date ' r Z Area <br /> Pit or Grout Inspection by Data <br /> Final Inspection by Date <br /> E <br /> Additional Comments: r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RM <br /> RECEIVED BY DATE PEIT'NO. <br /> F7 <br />+ EH 13.24 rREV.I/As I v <br /> rl <br /> EH 14-2e +� ( �ar <br />- <br />