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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 /> lC� 1 dh ? > ` J City Lot Size/Acreage <br /> Job Address t <br /> A. <br /> `j <br /> Owner's NamerVV,_L_10 `Address Phone41 I <br /> Contract&�� ' Wl' 9 ddress 1 .O r v 1 / J' License No. 3 ` Phone ' l - <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER p Monitoring well <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES # DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y <br /> INTENDED USE TYPE'OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS <br /> f_-1 Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_" Specifications <br /> I"1 Public 11 Other n 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 LI Type of Pump '_H.P. State Work Done <br /> Well Destruction ❑ Well piameter Sealing Material & Depth <br /> �v FilJb r,Material 3 Depth <br /> Depth I s , <br /> TYPE OF,SEPTIQ'.WORK; NEW INSTALkATION f REPAIR lADDITION ( I DESTRUCTION I I (No septic system permitted A public sewer is <br /> tirN, available within 200 feet.i <br /> Installation-will seine: Residence!� CommercFial Other <br /> w i <br /> Number of living units: Number ofrooms <br /> Character of soil to a depthof 3 feet: Water table'depth C� <br /> jSEPTIC TANK Type/Mfg. Capacity -No._Compartmilnta <br /> PKG, TREATMENT_PLT."D ! ' Method of Disposal f <br /> Distance to nee reWt :y Well,&5/ �T Foundation Property Line <br /> LEACHING LINE No. I9 Legth of lines ' TotalJength/size K <br /> FILTER BED n Distance to nearest. Welt.10(� "+" `Foundation Property Linea Sd <br /> SEEPAGE PITS Depth II __--Size _ <A Number _f f <br /> SUMPS Distance to nearest: Well Foundation j <br /> �_. Property Line �4) ^ <br /> DISPOSAL PONDS ❑ I� <br /> -sl-..hereby certify that I have prepared this application and that the work will.be dane_in--accordance with San Joequinocounty-ordinances,-.state lows,-and- .-.- <br /> rule s and regulatrons'of [he 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 shalt not <br /> employ any person in such manner as td$ecome subject to workman's compensation laws of California." Contractor's hiiing or sob-contracting 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." I� - <br /> The applicant mus call for a r utr <br /> 21 inspections. Complete drawing on reverse rde? _V <br /> Signed \ . `�- title: �7 _s Date: ` <br /> - FOR DEPARTMENT USE ONLY .l <br /> App, <br /> anon Accepted by "�',- �_r�yw Date Are'aI � <br /> Grout inspection by § �L%ta� final Enspection by ate <br /> Additional Comments:. I� <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> TFEnvironmehtkl Health Permit/Services <br /> 445 N San,Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE I� AMOUNT REMITTED �K ECEIV BY ATE PERMIT'NO. <br /> lNF <br /> EH t4-m <br />