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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)465-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES .1 YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) <br /> Application is hereby rade 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 —kRM1etJone of San <br /> Joaquin County Public Health Services. I _ <br /> Job Address 000 S" Corr"NC-�e City ,,I TS Lot Size/Acreage9{� <br /> Owner's Name' Y (?"VkMJ LA) AWaddress -s Phone <br /> Contractor !ren ONIL Q Address / So 6uT" V Allense No,Zy3r1i t9 Phone e23• Ga g4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION o Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ("1 Public "•Ll Other r1-DeEia�'""''`" Depth of Gidur-Se'al Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Done_ Q <br /> Well Destruction O t Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth- i O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I&K DESTRUCTION I I (No septic system permitted it public sewer is <br /> y 7 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. ❑ Method of Disposal Q <br /> { Distance to nearest: Well Foundation Property Line <br /> - 1 s <br /> LEACHING LINE r No. & Length of lines m — '-=Total length/site' <br /> FILTE BED f ( ance to near st: Well F urdation'"� '•^'Property-Line-°•S0-r <br /> Alla g 0 of �r<r �_ -- ,� r- 4hJ <br /> SEEPAGE PITS �4t epth. it Site Number <br /> SUMPS LI Distance to nearest: We 11 _______��Foundation7 Property Line r <br /> 6 4 <br /> DISPOSAL PONDS ❑ <br /> r <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 /Ile \ e•l <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 S <br /> employ any person in such manner.as to become subject to workman's compensation-lows-of•California:""Contractor's-hiring'or sub•contrai ing 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." <br /> The applicant I for all ►squired i pectians. Complete drawing on reverse side. 4 1 <br /> Signed ' Title: `-'- Date: <br /> FOR DEPARTMENT USE ONLY T LG <br /> 0/� t- f <br /> Application Accepted by I Date Area <br /> Pit or Grout Inspection byI f ' Data Final Inspection by or e&CAA Date /lv g3 <br /> Additional Comments: <br /> Applicant - Return all copies to San Joaquin County P b1Ac_wHealth Services <br /> Environmental Health Permit/Services ` <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 f <br /> 1 FFF _ � 999 <br /> fEEAMOUNT DUE AMOUNVREMITT ED CASH RECEIVED BY DATE PERMIT'NO. <br /> IN <br /> *� ,! 1 <br /> EN 17-2i INEV.ryM51 1 ! ♦� �yza y . 3 tf <br /> EN 144E r <br />