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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR Ir <br /> FROM DATE ISSUED <br /> r �VrLp to (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 Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> t `A <br /> Job Address City 4/0� Lot Size/Acreage <br /> i OWC <br /> Owner's Name Address `h - <br /> Contractor Address <br /> poi License No. ! ®WPhon <br /> t. t <br /> TYPE OF WELL/PUMP: 6/ a NEW WELL 0 WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIROTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ., <br /> INTENDED USE TYPE Of.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> {Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Fl Public (-1 ether ' F� Delta Depth of Grout Seal : Type of Grout <br /> I I Irrigation Approx. De th i Eastern< Su�f e'Sau0lnstaIIed by <br /> Repair Work Do� Type of Pump H.P. State Work bone <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth' <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve; Residence— wCommercial_ Other ° <br /> Number of living units: Number of bedrooms # ° <br /> Character of soil to a depth of 3 lest: 1 If Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f € Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line <br /> r <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to•nearest: Well ' Foundation Property Line f <br /> SEEPAGE PITS 11 Depth Sire Ntlmber� <br /> SUMPS U Distance to nearest: Well Foundation 3 `Property Line <br /> DISPOSAL PONDS ❑ ; <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 lags, 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: "I cavity that in the performance of the work for which this permit is issued, I shalt employ persons subject to wo/compansa- <br /> tion <br /> laws of Califor <br /> The applidaWmust c far all requir spect' s, Complete drawing on re r side. <br /> Signed X Title: ell ( Date: <br /> FO DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date Area <br /> Pit or Grout Inapection by, Date Final Inspection by Data s <br /> I <br /> Additional Comments: <br /> Applicant - Return all copies to; Sari Joaquin Country Public Health Services <br /> Environmental. Health Permit/Services <br /> 445 N San Joaquin Boic 2009, Stkn, CA 95201 <br /> FEE i <br /> INFO <br /> EE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY ATE PERMIT N0, <br /> . EH13-24(ACV.1/N 51 <br /> EH t1-26 <br />