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SAN JOAQUIN COUNTY PUBLIC 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 /> (Complete in Triplicate) r <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wont 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 Health14ervicea. (� <br /> Job Address - loll ~' city /n I C]Lot Size/Acreage 7 <br /> Owner's Name? C11-6 e- Address >CJ"" _— Phone -3 9?r <br /> P <br /> Contractor 71 7 C M,S PUM P-S -.Address AJ. Lrf i K),' License No. Phone 7q <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ET DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION I SYSTEM REPAIR 0 OTHER Q Monitoring fell C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK :2&'T SEWER LINES DISPOSAL FLD. PROP. LINE 6 r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS I06� <br /> INTENDED USE TiYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS <br /> M Industrial —Open Bottom 0 Manteca ' Dia. of Well Excavation Dia. of Well Casing <br /> w5omasticlPrivate ❑ Gravel Pack n Tracy Type of Casing Specifications <br /> I'I Public El Other l-1 Delta Depth of Grout Seal ype of Grout 9 <br /> I i Irrigation _ Approx. Depth 11 Eastern Surface Seal Installed by ,� I <br /> Repair Work Done ❑ Type of Pump 54A H.P. Il9 State Work Done <br /> 4� Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) A <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms M <br /> Character of soil to a depth of 3 feet: Water table depth <br /> S90TIC TANK 0 Type/Mfg F Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl , s 'Method of Disposal <br /> Distance to nearest: Well a Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total-Is ngth/size <br /> t FILTER BED n Distance to nearest: Well `�` Foundation * Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 eignatura 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature i <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 appfi must call for all r wired inspection Complete drawing on reverse side. <br /> Signed X Jtr� Title: d J Date: `0 ""q 21 <br /> FO DEP RTMENT USE ONLY <br /> Application Accepted by Date —&—Ares <br /> Pit or row nspection by <br /> Date '?� Final Inspection by e C a t�fl_- Date { <br /> IVILL <br /> Additional Comments: 6 r r` OA)IF <br /> ' <br /> Applicant - Return all copies to: San Joaquin County Public'Health Services <br /> Environmental Health Permit/services <br /> 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 j <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EM13.241REV.r/ntSl /� r' <br /> EM 14�Ie � 0-0 <br /> i a — 7 <br />