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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 E%PIRES 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 PublicHealth�S'�er�/vlic <br /> Job Address l��& } 1 nV}r l + y" 7%c6 Cit Lot Size/Acreage <br /> Owner's Nama0 t Address1 3lV o►�� t^+ IL�l Phone /2 I C <br /> s� <br /> Contract f 1.0 Address A t� ( WIz +, License No. a 2!ca <br /> t Phone 30-S' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> VI Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Iffigalion _.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P, State Work Dane _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAI 1ADOITIONK DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence <br /> k--*, available <br /> Other <br /> l <br /> Number of living units: --I— Number of be o ms //,� <br /> Character of soil to a depth of 3 feet: Water table depth V� <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ C71 t Method of Disposal <br /> Distance to nearest:. Well �_ Foundation Q Property Line .i5 <br /> � � 1 <br /> LEACHING LINE No. & Length of lines A Total length/size <br /> i <br /> FILTER BED n Distance to nearest: Well 50 Foundation Property Line <br /> SEEPAGE PITS Depth i !e Number <br /> SUMPS Ll Distance to nearest: Well 4' Foundation 1 64 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 Joaquiri 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 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 lays of CaVifornia." <br /> The applican st calf forqu ed inspections. Complete drawing an reve�rse1 side, <br /> Signed X Title: �!• Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2` Z — <br /> . ��� �� Area.��-- <br /> or Grout Inspection by Date Inspection Inspection b Data 1,21r .Y <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, P O Sox 2009, Stkn, CA 95201 <br /> CK <br /> Ll <br /> INFOE AMOUNT DUE AMOUNT RR. �EMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> . EH 14.2s 24IREV.+/x5+ <br /> EH tb /C' f 7' v� /! e, �� ✓ <br /> ///��� <br />