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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r' ENVIRON]dENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)458--3420 <br /> ` P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERSTE KPI RES 1 YEAR FROu DATE ISSUED <br /> f (COmplete in Triplicate) <br /> f 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 Health Services. �- <br /> 8. <br /> Job Address �`� {� _ City ✓S dry kit Size/Acreage <br /> - r <br /> Owner's Nam r ✓ u-� ress <br /> —`"��`� � Phone <br /> Contractor Address <br /> t TYPE OF WELL/PUMP: NEW WELL E) LicenseM6/y�?hens <br /> WELL REPLACEMENT it DESTRUCTION Cl Out of Service Well <br /> I PUMP INSTALLATION ❑ SYSTEM.REPAIR "t'1' OTHER Cl- <br /> DISTANCE Monitoring Well <br /> TO NEAREST: SEPTIC TANK SEWER LINESC7 <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLf <br /> OTHER WELL PITS/SUMPS .,.` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indust'al 15 Open Bottom O Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> C7 Tracy '4 Type of Casing_ <br /> I'i Public Ci Otherfl Delta Specifications r.. <br /> -� Depth of Grout Seal Type of Grout �- <br /> I ( Irrigation — Approx. Depth I Eastern Surface Seal Installed by <br /> 5a—TypeRepair Work Done e of Pump H,P, _Z. <br /> b <br /> Well Destruction State Work Don Q� <br /> ❑ Well Diameter Sealing Msterial &`Depth <br /> Depth Filler Material & Depth- <br /> TYPE <br /> epth TYPE OF SEPTIC WORK: NE,W,iNSTALLATION t I REPAIR/ADDITION I f DESTRUCTION I i I septic system Permitted it Publictaswer is <br /> Installation'will serve. Residence' Commercial— Other available within 200 feet.l ' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Water table depth 1 <br /> PKG. TREATMENT PLT, ❑ Capacity , No. Compartments <br /> t, Method of'Disposal � <br /> Distance to nearest: Well Foundation 'rty ' <br /> Property Line <br /> s. , <br /> LEACHING LINE Cl No. &'-Length of lines <br /> FILTER BED ; Total length/size <br /> ❑ Distance to nearest. Well Foundation� _ <br /> Property Line <br /> SEEPAGE PITS It Depth Size <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Well Foundation r <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with <br /> rules and regulations of the San Joaquin County San Joaquin county ordinances, state laws, and <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's coRoansition laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the follZorn <br /> ertify that in the performance of the work for whit this permit ii-issued, I shall em to <br /> tion laws of p y persons subject to workman's compensa <br /> The a scant mr all requir inspe¢ ' s. Complete drawing on'F er side. <br /> Signed <br /> Tills: F Date: <br /> _ U <br /> _ FOR DEPARTMENT'U5E ONtY <br /> Application Accepted by , = — ^•' ► <br /> _ Dare Z ,� rest d Z T <br /> Pit or Grout Inspection by <br /> Of <br /> fiDate ' Filial Inspection-by" 7 <br /> + .+, r <br /> Additional Comments: L.�� vs �, ate <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 /> FEEAMOUNT DUE AMOUNT REMITTED A <br /> INFO iJ.�/ yy CASH RECEIVED BY DATE <br /> EPERMIT'NO. <br />. H 13-21fREV.riK51 1 r �� <br /> EH 1/-2e ►1 O <br /> q z-3�I I B` <br /> r <br />