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{ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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 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 <br /> Health Services. Q� <br /> Job Address LI I F_- l ' A l Yt/t� � tV City Lot Size/Acreage <br /> t <br /> w er's Na ( ,a�`�'�dtii ' " - 1 + v• ✓� Phone <br /> �onIf r��"""'v� WOLWd ss Ue No. F'hon -V� <br /> e <br /> TYPE OF WELL/PUMP: NEW WELL``❑� WELL REPLACEMENt 5 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ in ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> estic/Private ❑ Gravel Pack C1Tracy Type of Casing_ Specifications <br /> I'I>Pubiic Cl Other 1-1 Delta Depth of Grout Seal Type of rout <br /> t,l Irrigations _.Approx, Depth I I astern Surface Seal Installed by <br /> RepairRWork Done ❑ Type of Pump H.p,�`�71 <br /> State Work Don <br /> Well Destruction ❑ Well Dial m tellt Jf* Sealing Material i Depth <br /> Depth l Filler Material ii Depth ZILW <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ! I REPAIR/ADDITION I I DESTRUCTION I ! {No septic system permitted it public sewer is <br /> `N, available within 200 feet.) <br /> Installation will serve: Residence_-_— Commercial_ Other <br /> Number of living units: * Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK A `CO . Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑;, Method of Disposal <br /> �� .� Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 'Nd. Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth �Size Number <br /> SUMPS EI; Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑, <br /> I hereby certify that i have prepared this:appiicauon 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 V� <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 taws 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." } r <br /> The applican u t call fo II. inspe, tions. Complete drawing on re a side. <br /> Sign d <br /> Liu ;Z& <br /> -1 PeNwl <br /> NT.USE ONLY <br /> L <br /> Application Accepted by Date�� V� L Area_ <br /> Pit or Grout Inspection by I 1 pate Final-Inspton by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Sail-Joaquin County Public Health Services <br /> t Environmental-Health Permit/Services r I , <br /> 445 N San Joaquin; P. O Box 2009„ Stkn! CA 9520..1 <br /> FEE INFO AMOUNT DUE AMOUNT�rR9IEMITTED^- CASH RECEIVED By OA PERMIT'N07r <br /> . EH13.24 IREV. <br /> EH 14a <br />