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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PHONE <br /> 445 N SAN JOAQUINSTOCKTON(2 <br /> P o Bog , CA 95201209)468-3420 <br /> A���,QU N C5 A g IT EXEoIRES 1 YEAR FROM DATE ISSUID <br /> ,;aA 30 P,LI �-k 1VkDvJlsI'�'" (Complete in Triplicate) <br /> VI", N�made to San Joaquin County for a permit to construct an install the work herein uladestions of Sans <br /> application <br /> is he by <br /> applicatiao��s P�ublicnHes�thiServicesh San Joaquin County Ordinance No. 51+9 and 18f52 and the Rules and Regulations <br /> Joaquin County Lot Size/Acreage <br /> City ' <br /> Job Address <br /> Phone <br /> Address 13 6 6 <br /> Owner's Name 17754 N. Hwy. 88 — <br /> Address License No <br /> OCL Phone 7 <br /> Contractor GOERR DESTRUCTION ❑ out of Service Well ❑ ! <br /> NEW WELL ❑ WELL REPLACEMENT C7 Monitoring Well C1 <br /> TYPE OF WELL/PUMP SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ SEWER LINES �--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL�.-- <br /> PITSISUMPS <br /> FOUNDATION ____---- <br /> YP-E=0f=WELL =PROBLEM AREA__CONSTRUCTION.$PECIFICATlONS <br /> - �-�IN.T.END_ED_USE— ­_TYPE_ a-- Dia. of Well Casing <br /> Dia. of Well Excavation <br /> Industrial 0 Open Bottom Q Manteca Specifications - <br /> C7 Tracy Type of Casing_ <br /> EI Domestic/Private L) Gravel Pack Type of Grout <br /> 1-1 Other nDelta Depth of Grout Seal <br /> I') Public Surface Seal installed by ngth <br /> I i Irrigation —, <br /> H.P, <br /> �- <br /> Repair Work Done (3 Type of Pump Se_alingrial 5 Depth <br /> Well Destruction O Welt Diameter -- Filler Material dr Depth + !� <br /> Depth <br /> available within 200 feet.) C <br /> TYPE of SEPTIC WORK; NEW INSTALLATION I i RE PAIR/ADDITION I_I DESTRUCTION I I iNo septic system permitted it public sewer is <br /> Installation will serve: Residence <br /> Commercial___-_Other r <br /> Number of living units; Number of bedrooms `-- Water table depth ' <br /> Character of soil to a depth of 3 feet: �, _Capacity------•- No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation-^�- Property Line --- <br /> Distance to nearest: W811 <br /> ..T-- p Y - <br /> t. _-.- _,..� m �- : - otal-iength7size <br /> """ <br /> LEACHING LINE ❑ No-&'Length of lines' _ _ - _T_ -Proert .Lana <br /> FILTER BED <br /> 1 ❑ Distante'to-nearest: W811 - Foundaiion ��-- <br /> F <br /> iSize — Number <br /> SEEPAGE PITS t I Depth Property Line <br /> SUMPS <br /> 1 <br /> LI Distance to nearest: Well Foundation <br /> q <br /> DISPOSAL PONDS ❑ _ - ordinances state laws and <br /> r accordance th _2_-^mow <br /> I hereby_certify that.) have prepared his and the the.work-will be done-in accordance with San Joaquin county_._,__-- . <br /> rules and regulations of thr---'an Joaquin County' following:he work for <br /> l not <br /> Home owner or licensed ogee' eggs to beccortme subjects to workman's <br /> rtcompensation lawsofCalifornia."Contractor's 1hiri g or sub-contracting ch this permit is isignlature <br /> 1 employ any person in such <br /> certifies the following:" that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen <br /> sa- <br /> tion laws of California' <br /> The applicant mus I r q inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> 4 Signed <br /> i OR EPARTMENT USE ONLY p, - j <br /> k Da�b� <br /> e i� 1� Ar © Lt <br /> Application Accepted by j�_ <br /> Date <br /> '+ Pit or Grout Inspection by <br /> Date_ Final Inspection <br /> Additional Comments <br /> I Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> GA 95201 <br /> 445 N San Joaquin <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK RECEIVED BY TE PERMIT NO. <br /> INFO <br /> . EM 17-241(REV.I I" <br /> 9 <br /> EH 14-26 <br /> I <br />