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.. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 � - <br /> j p O BOX 2009, STOCKTON, CA 95201 <br />! PERM] EgPIRES 1 YEAR FROM DATE ISSRED v. <br /> (Complete in Triplicate) a <br /> Application is hereby made•to Joaquin countyliance with San lor a. pe mitordtonconstructaand/or <br /> and iininstall <br /> the eherein work s <br /> Rules and Regulations of San <br /> application is made in camp <br /> Joaquin County Public Health Services. <br /> G, <br /> f Ca City Yl Lot Size/Acreage �- <br /> Job Address I S <br /> -5Phone <br /> Owner's Name ] ,S � irhddress <br /> Address 1", V- Q License No <br /> Phon� <br /> Contracto DESTRUCTION 0 Out of service Well , 0 <br /> TYPE Of WELL/PUMP: N W WELL' WELL REPLACEMENT ❑ OTHER ❑ M°nitoringlWell3 + �� <br /> PUMP INSTALLATION SYSTEM REPAIR Q <br /> 3 SEWER LINES __ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK - -� <br /> AGRICULTURE WELL OTHER VdELL PITSISUMPS <br /> FOUNDATION I 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATIO S i Industrial i ' <br /> etl Casing <br /> C1 Open Bottom 0 Manteca <br /> Dia, of Well Excavation Dia. of W <br /> � Specifications . <br /> Type of Casing_. A <br /> Domesticl Private ❑ Gravel Pack ❑ Tracy o rout rt <br /> C] Other n Delta Depth of Grout SealG <br /> Type- <br /> I'] Public p� w 1/it_/ 1� U - <br /> I ] Public <br /> c� Approx. Depth I Eastern urface Seal Installed by <br /> i _ State Work Done, <br /> Repair Work Done L7 Type of Pump H.P. <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter F11ler Material & Depth <br /> Depth <br /> TYPE Of SEPTIC WORK; NEW INSTALLA710N I 1 REPAIR/ADDITION l I DESTRUCTION I I avail blerwAhin 200 feed.led it public sewer is <br /> Installation will serve: Residence— Commercial Other — <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> ChAracle, of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of"Disposal ' <br /> PKG.'TREATMENT PLT. ❑ <br /> Discs 10 nearest ,~Well Foundation Property Line <br /> y <br /> % - <br /> ` �- Total length/size <br /> LEACHING LINE 0 No. & Length of tines <br /> FILTER BED Property kine " <br /> ❑ Distance to nearest: wellFoundation <br /> SEEPAGE PITS 11 Depth Size <br /> �. Number <br /> SUMPS <br /> L! Distance to nearest: Well___L==—__ Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> k 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 s permit is issued <br /> Home owner or licensed agent's signet <br /> workman's compensation laws of California.;'ure certifies the following: "I certify that in the performance of the work for which thi ; l s <br /> ggall"not <br /> employ any person in such manner as to become subject to Contractor's hiring or sub-contractin si nature <br /> I e work for which this permit is issued, I shall employ persons subject to warkman's'compensa- <br /> eertif;ei the following: "I certify that in the performance of th , <br /> tion laws of California." <br /> The applicant must call for all required inspections. Camplete drawing on reverse side. T <br /> Signed dfI A 4.4 A AQAN Title: _S_ez IF PT e-S Date: <br /> r FOR DEPARTMENT USE ONLY. <br /> dz rr - <br /> . --- • Date A <br /> - � rea <br /> Application Accepted by <br /> -— <br /> P <br /> I��- ��- Final Ins ectioDate r <br /> Pit"or Gybut Inspection by Date n by P ...:,...,—_-- •- -• <br /> Additional Comments: j <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> EM <br /> CK RECEIVED RY DATE PERMI-F NO. <br /> ' DUE AMOi7mwT7.> <br /> ITED Em13-24IREQ y <br />