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SAN JOAQUIN COUNTY•PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL ZEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ?"-"p 4PERMIT 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. 549 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Service . <br /> Job Address r City Lot Size/Acreage <br /> 00141 Phone <br /> Owner's Name Address <br /> Contractor Addres� � �f 1CS_eT,4._0_2 License 1V� Phone <br /> TYPE Of WELL/PUMP: NEW WELL LJ WELL REPLACEMENT n DESTRUCTION L1Out of Service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ) OTHER p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack* ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public CI Other fl Delta Depth of Grout Seal Type of Grout - --- <br /> I I Irrigation —..Approx. Depptth�/I�l Eastern Sur a Seal Installed by Y <br /> Repair Work Done A 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 I 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'. <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. ❑ Method of Disposal r� <br /> Distance to nearest: Well Foundation Property Line fy <br /> LEACHING LINE ❑ No. & Length of lines Total length/size `• <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ul 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 sub-contracting signature <br /> certifies the follow' " certify that in the performance of the work for which this permit is issued, t shall employ persona subject to workman's compensa <br /> tion laws of i ornia." <br /> Thea cant must I for all required i ctio Complete drawing on r er side. <br /> Signed X Title: Date: Zo <br /> (� FOR DEPARTMENT USE ONLY <br /> Application Accepted by c" ;`, Date IZ� Area t2 2 1` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> A* <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 0 Sox 2009, Stkn, CA 95201' <br /> FSE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM11'N0. <br /> INFO <br /> . EM 13.24iREV.riN5! <br /> EH 14.20 _..7 <br />