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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 01 PERMIT ESPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made toSan <br /> ce V�hugenCJoaQuinfor <br /> County ordinanceNo. '549and/or <br /> 1662install <br /> a.nd thethe <br /> Rules andherein <br /> Regulations of SanThis <br /> application is Public Hein alth Services. <br /> Joaquin County <br /> City Lot Size/Acreage <br /> Job Address <br /> , ` Phone <br /> Owner's Name Address <br /> � !_ License No Phone <br /> ContractoLsa` Address <br /> WELL REPLACEMENT DESTRUCTION C} Out of Service Well Cl <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Monitoring Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —— <br /> DISPOSAL FLD. PROP. UNE <br /> FOUNDATION' _. — AGRICULTURE WELL�"'OTHER WELL— "" - PITS/SUMPS <br /> ,. <br /> INTENDED USE = TYPE OF WELL r jPROBLEM AREA CONSTRUCTION SP>=CIFItt�ATIONS Dia. of Weil-Casing, <br /> - - Open Botfom�- F-�(] Manteca ' Dia:-of Well'ExcavStion <br /> -TC}industrial - Specifications <br /> ,OomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> . Other <br /> Cl De Depth of Grout Seal Type of Grout <br /> 1'1 Public f <br /> I i Irrigation —.Approx. Depth �°C11 Eastern Surface Sea! Installed by <br /> State Work Done <br /> Repair Work Done-A Type of Pump i' r H.P. `l _. <br /> ew �,3ealing Material & Depth. <br /> Well Destruction ❑ Well Diameter f , .� r <br /> Depth ' Filler,Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I+I REPAIR/ADDITION'l•1 DESTRUCTION I I INailseptic ystem00 refeetnted if public sewer is <br /> �• l ~� <br /> 11 <br />� k ' <br /> Installation will serve: Residence CommeFcial _ — <br /> Number of living units: Number of bedrooms ( WaupArjarm <br /> Character of soil to a depth of 3 feet: - <br /> SEPTIC TANK.: ❑ Type/Mfg f x,!,CapacityNo. <br /> Mach%of �isp�sa <br /> PKG. TREATMENT PLT.❑ # ti ' <br /> f F-, Distance to nearest: 1 Well Foundation Property Lipa <br /> ' CUNTY <br /> Total length! <br /> LEACHING LINE ❑ No. & Length-of lines � h <br /> ` kr <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> P� �q�p1E S AL <br /> t _ <br /> r , <br /> SEEPAGE PITS 11 Depth ( Sita Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 111r <br /> DISPOSAL PONDS O <br /> hereby_conify that.,l-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 /> I 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 /> f certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall employ persona subject to workman's componsa- <br /> tion laws of California." ' <br /> The applicant must caN for all required ins�ctions. Complete draw'' n reverse side. <br /> "Signed <br /> Title: Date: <br /> Si <br /> g E ONLY. <br /> DEPARTMENT.US (^ n J <br /> Date �I�r�� y Area /{/(.��--..•r <br /> Application Accepted by / <br /> f Pit or Grout Inspection by Date <br /> Final Inspection by ' Data <br /> i Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services �( <br /> y Environmental Health Permit/Services]' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ' FEE AMOUNT DUE AMOU T REMI D CASH ECEIVED FM D TE PERMIT'NO, <br /> . EN 13.24(REV.f i n 5) Lj �7V <br /> EH 1 .16 <br />