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z <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> f PERMIT 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 <br /> Joaquin County Public Health Services. �]� <br /> Job Address �� . '� h "�—` J _ CityAeampexLot Size/Acreage <br /> (° $ <br /> Owner's Name' Address Phone <br /> ^- <br /> Contractor f I G H Address.p Q•BID%4_tl( License No.0gRSZZ phane�[�7�a <br /> TYPE OF WELL/PUMP: NEW_ WELL ❑ + WELL REPLACEMENT F.1DESTRUCTION t of Service Well ❑ <br /> PUMP-INSTALLATION••❑i:- ;.�– ---SYSTEM REPAIR,❑„,,..# OTHER ❑ Monitoring Well <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL -- PITS/SUMPS <br /> INTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_-I Industrial 'i ❑,Open Bottom ❑ Manteca Dia. of Well Excavation -r Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing. Specifications <br /> I'] Public Cl Otherx.1-1 Delta Depth of Grout Seal E Type of Gfout V 1 <br /> / <br /> I I Irrigation —.Approx. Depth I/Eastern Surface Seal Installed by f Q <br /> Ik Repair Work Done 0 Type of Pump' H.P, tate Work one •�h <br /> k Well Destruction'' Well Diameter Sealing Materiel & Depth e K 0 (+i l7 1 <br /> i • ° Oep' <br /> +T _ Filler Material & Depths ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> 1, available within 200 feet.I <br /> Installation will.serve:,Residence— Commercial— Other i t <br /> Number of living•units: Number of bedrooms 1 f <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. 0 Method of Disposal <br /> 1 ` <br /> ,Distance to nearest: Well Foundation Property Line y_ <br /> f <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> f ► s <br /> FILTER BED [� 'DiDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property line r <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 /> ruies'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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The applicant must call for all required inspections. Complete drawing on reverse side. + <br /> Signe Title: �� � pate: <br /> FOR (DEPARTMENT USE ONLY Vr <br /> 1 7 /2 <br /> Application Accepted by -� ---- Date & Area <br /> Pit or Grout Inspection by Date Final Inspection by 7r ori 1. Date <br /> s GFe!(r� <br /> AdditionsiXomments:.- - ---- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services `R ""�114445 N San Joaquin, P O Box 2009, Stkn, CA 95201 { <br /> FEE AMOUNT DUE AMOUNT REMtTTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO —/} <br /> / r y` <br /> • EH 12<(REV.4 N 51 <br /> EH 14.�•2e `E' � <br />