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SAN JOAQUIN COUNTY PULIC H�LTH SERVICES <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> c <br /> f � � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> P f "" (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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ServiS s. <br /> Job Address in <br /> . _ City ' Lot Size/Acreage <br /> e�� C <br /> l <br /> Owner's Name G.f~ k r, f V Address 50- OOW Phone <br /> Contractor//1y O T S •_Address OON License No �C� (L Phon <br /> TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT P DESTRUCTION C Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRS OTHER ❑; M Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Yoomestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'l Public -1 Other fl Delta Depth.of Grout Seal Type of Grout <br /> i I Irrigation * ��..Approxi Depth I Eastern -� Surf' a Seal Installed by <br /> Repair Work Done )K Type of Pump H.P. State Work Dana ti <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth + <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is <br /> 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. ❑ Type/Mfg ` Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ . .r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines l Total length/size <br /> FILTER BED ❑ Distance to nearest: :,;Well ' t Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS , �� ` :Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 'y f <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 /> 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 /> cenifies 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 Calif rnia.' <br /> Thea cant must c 11 for all required i ctions. Complete drawing on rover �idtt. <br /> Signed X Title: __ � Date: <br /> w- FORREPARTMENT USE ONLY �]2�4 <br /> Application Accepted by C&a N. - .1►�-�.a+. Date `f l7'�+ Area <br /> Pit or Grout Inspection by Date Final Inspection by — Date LZ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY ATE I— <br /> N0. <br /> . EH,7.24 <br />\ <br /> EH 11.2E <br /> 1 , <br />