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M SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> i <br /> f 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 Servilces. <br /> I <br />! Job Address w City of Size/Acreage <br /> I <br /> Owner's Name t L GZ1N L Address <br /> � �� iT� � T ����"� N �J1�S�lA.. — Phone <br /> Contract r �.� �• c <br /> a rens �2,. License No.�6Z.3�3 Phone �OE]�ibZ <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 177 DESTRUCTION C1 Oyt of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR. OTHER` Monitoring Well L7 <br /> dDISTANCE TONEAREST: SEPTIC TANKi <br /> SEWER LINES - __ DISPOSAL FLO. PROP. LINE <br /> ! <br /> FOUNDATION; AGRICULTURE WELLr OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom © Manteca Dia.,of Well Excavation Dia. of Well Casing <br /> El <br /> D�Domestic/Private 0 Gravel Pack l El Tracy, Type of Casing_ Specifications <br /> 11I'Public Cl Other (l Delta'i Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth��I I Eastern'' Surfac1e Seal Installed by <br /> Repair Work Done 0 Type of Pump S� b H.P. /\ State Work Done <br /> Well Destruction O Well Diameter 6ealineMa-Cerial 3 Depth <br /> Depth Filler Mineral A Depth <br /> r f, <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION Int' DESTRUCTION-! i )Ivo septic system permitted if public sewer is <br /> ' `available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other f� <br /> Number of living units: Number,of edrooms, <br /> Character of soil to a depth of 3 feet: `'' `.` 4 ?'+ \Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity rte. No. Compartments <br /> PKG. TREATMENT PLT.ClFyt`'": f e Method of Disposal <br /> t t <br /> Distance-to.nearest: Well Foundation�_ Property Lina <br /> LEACHING LINE C1 No. &'`Length oflinesTotal length/size <br /> FILTER BED ❑ Dista"nce to inearest: W ouncation, Property xine <br /> SEEPAGE PITS 11 `depth Sue ~' Number '. <br /> SUMPS LI Dislancefto nearest: Well Found8fio * `r-Property Lina <br /> DISPOSAL PONDS D <br /> I hereby certify that I have prepared this application and that the work will be,do✓ ih accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San,Joaquin County <br /> Home owner or licensed agent'signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ! shall no <br /> employ any person' manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil tng: "I c ify that in the rformance a work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion lawe.of I)fo ia." <br /> The applic t m all requi d i plate rawing on r or sid�::�r <br /> Signed Ties: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byZQIM-IAS{ 1 s DateArea <br /> 1 <br /> Pit or Grout Inspection by Date Final Inspection b Data �� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE <br /> -^ AM N/T�JR�EMITTED C K H RECEIVED BY DATE PERmrr'NO. <br /> . EH 1 <br /> 4•21[lIEV.iiww ii (® <br /> EH 11.2e �/J�+ <br />