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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 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 Health Services. <br /> Job Address + City Lot Size/Acreage <br /> Address �ye��'A �10 Phone <br /> Owner's Name. _ <br /> Contract AddressAgAv_71License No. Phone <br /> TYPE OF WELL/PUMP: t e�- , NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well C7 <br /> i. PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER Cl Monitoring Well 0 <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 /> FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing------------- Specifications <br /> I'l Public Cl Other Ll Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —,.Approx. Depth I I Eastern Surface Seal Installed by ; <br /> Repair Work;Done U Type of Pump H.P. State Workk-rpone _ <br /> Well Destruction ❑ Well Diameter Sealing Material.& Depth <br /> Depth Filler Material & Depth­: r , <br /> TYPE OF SEPTIC WORK: NEW INSTAL ION l I EPA'IR! OOITION X DESTRUCTION i I ffVo 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 be f. oms <br /> Character of soil to a depth of 3 feet: � - � <br /> __Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ -� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE <br /> Cl No. is Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well f Foundation Property line <br /> SEEPAGE PITS I I DepthSizeumber t - <br /> SUMPS Distance to nearest: Well Foundation 1,0_- -- Property Lineham^ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in4ccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County = T <br /> y <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,1 shall n <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor s,hifing 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 per subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for required inspections. Complete drawing on reverse side <br /> Signed X Title: Date: <br /> .- <br /> 0 <br /> FOR DEPARTMENT USE ONLYti.�_y* Y� q <br /> Application Accepted by Date [ Z- - Area <br /> 7 <br /> Pit or Grout Inspection by Date ' Final Inspection by Date <br /> Additional Comments._ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmen'tal °Health Permlt/Services <br /> - 445 N Sari'Joaquin, P O Box 2009, Stkn, CA 95201 <br />` FEE AMOUNT DUE AMOUNT REMTTED CASH^ RECEIVED BY DATE PEAMIT'NO. <br /> r • m 13-24(REV, <br /> 11.24 <br /> E <br />