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SAN JOAQUIN COUNTY PUBLIE: HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> pi P O BOX 2009, STOCKTON, CA 95201 <br /> 7, �Qp�., 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. R J I <br /> C <br /> Job Address City Lot Size/Acreage <br /> Owner's Name �f Address 5C6._ Com'-(�r_ Phone <br /> Contractor Address9_._K9 r— �� License Iv Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR f� OTHER ❑ Monitoring Well <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 /> n Industrial ❑ Open Bottom I❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> C1 Public (-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. De�th+ i I Eastern Surface Seal Installed by <br /> Repair Work Done � Type of Pump ` aL�h= H.P. - State Work Done <br /> t000v <br /> Well Destruction ElWell Diameter Sealing Material & Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 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 <br /> Distance to nearest Well Foundatlon Property Line10 <br /> (� <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED Cl Distance to.gaarest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <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 <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 not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring 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 persons subject to workman's ompensa- <br /> tion laws of C <br /> Thea ant mu call far all required ctions. mplete drawing on rover e. <br /> Signed X Title: Date: <br /> FO DEPARTMENT USE ONLY <br /> ItApplication Accepted by �+rean. ltb� DatArea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public HealthService <br /> Environmental Health ermit/Services <br /> 445 N San Joaqui Box 2009, S , CA 95201 <br /> FEE INFO AMOUNT DUE AM UNT REMITTED CK R EIVED BY DAYE <br /> PERM17'No. <br /> . EH 13.24{flEV,rims) rf�`� <br /> EH 14 28 �l <br />