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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin Count for f <br /> pp y q y 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 tl <br /> Joaquin County Public Health Services. <br /> LIS ja "� eJ City a8 <br /> Job Address �. � 1 Got Size/Acreage <br /> e ( i <br /> w e <br /> re Address`, S __ Phone Y <br /> �rsy�N�a]me�M <br /> W1Cii T 1� W 's Q� Q <br /> ontractor T t - .__ dd^+ddress 1 5. E Nc. lJ Phone(4 31-, <br /> TYPE Of WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'Monitoring WellAl <br /> DISTANCE TO NEAREST:v 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 /> D Industrial © Open Bottom - rf9 Manteca Disko(Well Excavation Dia. of Well C@sing <br /> estic/Private 0 Gravel Pack ;'v.L7 Tracy Type of Casing. Specifications <br /> I'I Public 1-1 Other Cl Delta Deptti,of Grout Seal Type of Gro t <br /> I I Irrjgation_, ..Approx. Depth 1 JjEastern SurfaceSeal Installed by <br /> Repair Work;Done U Type of Pump H.P._ , j State Work Done <br /> Well Destruction )+/❑I�Well Diamefir Sealing Material & Depth <br />.. <br /> ;'"°"'4 _ _. Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if,p6blic sewer is <br /> 1 n . available within 210 feet.) <br /> installation will serve:`^Re`sidence +,-.,Commercial__._ Other j { <br /> Number.of living units: Number'of bedrooms <br /> Character of soli tia,a-depth_of-3-feel: + Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity1 -No.-Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r ` <br /> tr- Distance to nearest: Weil-N ;__ Foundation Property Line <br /> LEACHINUNE ❑` Na. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS 0 <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 following: "Iahat in the performance of the work for which this permit is issu d, I shall employ persons subject to workman's compeensa- <br /> tion laws of Cafifocnia,"The applican m st call fi ins ions. Complete drawing on r sr. e <br /> Sign X 49 4 Tit Date:le�AZIV4 <br /> a <br /> '�� FO�ARTMENT USE ONLY , <br /> Application Accepted by L.C. }� ,�t,� Date Z Area <br /> Pit or Grout Inspection by Date r 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 /> r <br /> FEE <br /> INFO `MOUNT DUE AMOUNT REMITTED CASH CK 11 AECEiVEO BY GATE PERMIT•NO. <br /> . EK 1J-21(REV.1 i n 61 <br /> EH 71.20 S, �� �© 2J 10 .� a - <br />