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Oq <br /> M - �J( AQUIN <br /> -COUNTY- <br /> SANi��JBL � TU SERVICES <br /> „ '` 3 •". _. ExviR-0NMENTAL`-HEALTH DIVI�•.ION <br /> 445 N SAN JOAQUIN,,,,:PHONE° (209)4683420 '� <br /> _ P 01-BOX 2009, STOCKTON, CA 95201 <br /> •� ' <br /> PERMIT EXPIRES 1 YEAR FROM:'DA E ISSUID <br /> (Complete in Triplicate) .J <br /> r' J oa'uin County for a permit to construct and/or install the ork herein described. This <br /> Apglir_ation is hereby made to'_San J q <br /> application is made in coumpliance with San Joagdin County Ordinance'No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �j TD"S_1 J. L �� City Lot Size/Acreage % <br /> Job Address L AJ l K ar { <br /> � Phone <br /> Owner's Name V Address <br /> I }Contractor ��4 <br /> Addres Zaft E_icense N Phonen�LWELL REPLACEMENT DESTRUCTION ❑ Out oP 8erviceWell L1TYPE Of WELL/PUMP: NEWELL ❑ OTHER ❑ Monitoring Well' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> .� SEWER LINES DISPOSAL FLD. PROPi LINE « <br /> �DISTANCE,TO NEAREST: SEPTIC TANK ` OTHER WELL PITS/SUMPS <br /> y <br /> FOUNDATION � AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casin <br /> C1 Indlustriaal g.Open Bottom ❑ Manteca Dia. of Well Excavation _.-S 't <br /> Type of Casing Specifications <br /> Domestic/Private ❑ Gravel Pack 0 Tracy �- Type of Groui <br /> +., i"1 Piahlic Cl Other i'1 Delta Depth of Grout Seal <br /> i I lrri{salion —Approx. Depth I 1 Eastern r <br /> Surface Seal Installed by <br /> Repair Work Dane Type of Pdmp H•P I r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth , <br /> Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I i availabe within 200 feettled II p"b5c sewer is <br /> Installation will serve: Residenc©'?�--Cvmme*tial — Othec• �__ <br /> Number of living units: Number of bedrooms Water table depth <br /> ! Character of soil to a depth of 3 feet: <br /> Capacity Na. Compartments <br /> SEPTIC,TANK 0 Type/Mfg Method of Disposal <br /> PKG. ptEATMENT PLT.El <br /> Distance to nearest: ' Well Foundation Property Line - <br /> LEACHING LINE D No. 8 length of lines Total length/size <br /> FILTER BED ' 0. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size �"� Number " <br /> SUMPS Cl Distance to nearest: Well foundation Property Line <br /> f . <br /> DISPOSAL PONDS ❑ <br /> that the work.will be done in accordance with San Joaquin county ordinances, state yaws, and <br /> I hereby certify that I have prepared this application and <br /> rues and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify in the performance of the work for which this permit is issued, I 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 compensa <br /> tion laws of California." *- <br /> ' The applica t mu all for r wired inspections. Complete drawing on reverse side. N,1 <br /> I <br /> .Eh/uJt� Date: - <br /> Signed Title: <br /> OR DEPARTMENT USE ONLY f 9 <br /> Application Accepted by <br /> Date � <br /> Date final Inspection by Data <br /> Pilot Grout Inspection by =� <br /> r <br /> x ! U <br /> A •ional Comments. r y��} <br /> Appticant -• Return all copies to: San Joaquin County public Health Services i� �� 4 <br /> _ ! Environmental Health Permit/Services , <br /> �� 4'L 445 N San Joaquin, P D Box 2009, Stkn, GA 95201 ��2ri <br /> YP � -1VrJ <br /> RECEIVED BY DATE PERMIT'NO. <br /> A U E AMOUNT REMITTED GASH Z <br /> INF <br /> EH Ly �v9 t la <br /> - « fN13.21rR .1/N5l p �Q � <br />