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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -� r <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> w 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201NCD(AkJ 1 <br />( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ck •�► . <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fora <br /> application Is made in c Permit to construct and/or install the work herein described. This ? <br /> alliance with Ban Joaquin County Ordin 49 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I I <br /> Job Address c ted-'I T 9 p 'r I t4 I u'{ � <br /> V Lot Size/Acreage <br /> 1 <br /> +s <br /> Owner's Name Address hole l� I <br /> �r V =Lceme <br /> ConlraclorAddress <br /> Phone , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <br /> DIS NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTE D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L} industrial; ❑ Open Bottom D Manteca Dia. of Well Excavation <br /> Dia. of Well Casing ) <br /> C] Domestic�iPrjvat ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> VI Public '�,- f-1 Other fl Delta <br /> Depth of Grout Seal Type of Grout <br /> I I Irri{fation ..Approx. Depth [ I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type o ump H P ��----->-- <br /> StatetWork Done T t <br /> Well Destruction ❑ Well Diamet Sealing Material & Depth { <br /> Depth Fi11er,Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION i I DESTRUCTION VNo septic syste rmitted if public sewer.is <br /> Installation will serve: Residence t R available wit 06 feet.) <br /> f <br /> Gomrnerciel Other <br /> * .^i <br /> Number of living units: Number of bedrooms � , <br /> Character of soil to ah of,3 feet: <br /> ,-SEPTIC TANK. ❑ T .:( f r f Water table depth <br /> YPe g — - - Capaci No. Compartments i <br /> PKG.'TREATMENT PLT. ❑ " f <br /> • !t�IVFetfi"ed`��6isposat, <br /> Distance to nearest: Well un n Property Lina. -�: <br /> s <br /> f ._ <br /> LEACHING LINE ❑ No. & Length of lines f_ <br /> Total length/size � <br /> FILTER BED n Distance to nearest: oil Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> Number <br /> SUMPS LI pial a to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property L1 <br /> I hereby certify that tDsle prepared this application and that the work will be done in accordance with San Joaquin counNrdinances, tate laws, and <br /> rules and regulati of the San Joaquin CountyHome owner icensed agent's signature certifies the following: "i certify that in the performance of the work for which tued, I shall not <br /> emplo y person in such manner as to become subject to workman's compensation laws of California."Contractor's hirincting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em Iotion laws of Cafifomla." p y persons sun's compensa- <br /> tion <br /> applicant must call for all req red inspections. CAMploie drawing on reverse side. <br /> Signed -7 �i f� i <br /> Title: <br /> Date: <br /> FO PARTMENT E ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by l <br /> Oats Final Inspection by Date�Fv � <br /> Additional Comments: ' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1341 PREY.r/ASl ® 0 ` ®� 3.7 7 <br /> EH 14-M <br />