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O <br /> SAN JOAQUIN COUNTY P�TBLI:C 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> e of (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 <br /> Joaquin County Public Healjth�ervices. c <br /> Job Address �Q "'v 4 City �? _^ Lot Size/Acreage <br /> I <br /> Owner's Name Address _ �+D►-_WL Phone <br /> _ <br /> I <br /> Contractor L <br /> Address License �2W_=Phone a� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <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 L`1 Manteca Dih. of Well Excavation_' __ Dia. of Well Casing <br /> C.1 Domestic/Private n Gravel Pack n Tracy Type of Casing— Specifications <br /> 'Public ;I.1 Other "�.� Delta "Depth of Grout Seal Type of Grout <br /> _ ,,f r <br /> I I Irrigation ` .Approx. Dept I £astern Suri a Seai Installed by <br /> Repair Work Done Jt>i[ 42 <br /> Type of Pump H.P. AState Work Done <br /> Sealing Material <br /> Well Destruction ❑ Well Diameter <br /> & Depth 1 <br /> Depth• Filler Material A'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLY. ❑ Method of Disposal. <br /> Distance to nearest: ,r Well Foundation Property Line <br /> LEACHING LINE D , No. & Length of lines I Total length/size y <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I ..Depth Size Number <br /> SUMPS Ll� '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 /> ensation lawn of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's comp <br /> "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjec;Zroar�,work 's <br /> compensa-tion laws of Californi ' <br /> The ap nt must ca or all required ins tions. Complete drawing on r�ere�side.Signed XTitle: /f ( S Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted byC�� o� ---- Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date A)Oz, <br /> Additional Comments. <br /> Applicant -• Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health P mit/Services <br /> 445 N San Joaquin sO_B x 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK R CEIYEO BY p TE PERMIT NO. <br /> INFO <br /> • EN t3-2�IREV.i i n sr C tl 4;;�I o o A ( 56 <br /> Yi <br /> EH i1•Id <br /> l <br /> I , <br />