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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 0 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 <br /> ~ a �of/ an <br /> Joaquin County Public Health Services. R�pp � _ <br /> ,I <br /> Job Address 0 City Lot Size/Acreage fZR� <br /> C_ <br /> Owner's Nam Address <br /> Contractor "_�LAddres License Ng�J_2?5)r76 Phone <br /> 2b;e� <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR�i OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom p Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F.) Domestic/Private ❑ Gravel Pack7 n Tracy Type of Casing_ Specifications <br /> Cl Public Cl Other fl Delta Depth of Grout Seal Type f Grout <br /> *irrigation _Approx. D t a kastern fe Seal Installed by <br /> Repair Work Done Type of Pump e 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 1 REPAIRIADDITION f I DESTRUCTION I l 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 _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <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 in accordance with San Joaquin county ordinances, state laws, and <br /> 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 subcontracting si atufe <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 c pensa- <br /> tion laws of California." <br /> The applic st 2callr all required inspe 'ono. Complete drawing on re arse ide. <br /> Signed X Title: Date: <br /> 1�� R PARTMENT USE ONLY q <br /> Application Accepted by M l __.._. Date `r $� t— Area 2— L <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional 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 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DVE AMOUNT REMITTED CK ECEIVED BY ATE PERMIT'NO. <br /> �/ <br /> . EM 13.24IREV.i it 51 t �� <br /> EH 14-26 <br /> i <br />