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y SAN J04QUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> j 445 N SAN 4OA�QUII , ;PHONE (209)468-3420 <br /> +. P 0 BOX 2006; STOCKTON, CA 95201 <br /> ilk i <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 ' t <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 /> 74F-4346 <br /> Job Address if, +a✓ CityZj&)"Lot Size/Acre eLa # <br /> f �:. <br /> ".11111144- <br /> yYOA <br /> wner's NaeAddress 40 )Dj3Aeo Phone ` s e ,ti <br /> License No.' 6 373Phone QL <br /> ZContractomAddress a <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION L, Out of Service Well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 .00Ve#1AR &000' Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />+ FOUNDATION AGRICULTURE WELL OTHER WELL � � PITS/SUMPS _v <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I.) Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing._.. Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of rout <br /> I I Irrigation / Approx�,�Depth I I Eastern S Seal Inst ailed by <br /> Repair Work Done L Type of Pump �� H.P. State Work Done <br /> Well Destruction o Wt lr D,iar!t�leter Sealing Material & Depth <br /> wt-7 <br /> \ r <br /> Depth � Filler INa$etria'�«;.,Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLAJION I I REPAIRIADDITION IJ NIPS3i11JCTION I I (No septic system permitted if public sewer is {1, <br /> s•»- - available within 200 feet.) `\l <br /> Installation will serve: Residenc Commercial_ ther 1 f, <br /> Number of living units: N ber of bedrooms'. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT.PLT. D Method of Disposal I; j <br /> Distance to near Well Foundation Property-Line `~ <br /> „�,�'�.►... _,.,......�.,.--.-,...,..�..,... __-„_, _ ,..w....,�...-...._..,....-+.,-�., .---w-�.......,..._to _ _� - . <br /> 'LEACHING LINE ❑ No. & Le/tne0arest; <br /> f lines' ' t Total length/size <br /> FILTER BED n Distance ;� 'II % �_ `',F>5uritlatiori Property Line _ <br /> SEEPAGE PITS 11 Depth Sire Number f <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 lic ent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not°I: <br /> employ any Pe n in such nner as to bee m bjeCt to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I <br /> certifies the f Iiowing: "Ice i}y that' t ape r nce of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws o Califor la." <br /> The appli nt u t all r ions. mplate drawing on r r side. / u <br /> Signed X Title: r Date: <br /> o <br /> RARTMENT USE ONLY <br /> Application Accepted by _ �.� �- � Date Area <br /> Pit or Grout Inspection by Date Final Inspection by � '�'�-��-�--A DateZ Zlt4�1 7 <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 Box 2009, Stkn, CA 95201 )t <br /> # <br /> f <br /> INFO <br /> EEE AMOUNT DUE AMOUNT/REMITTED /C/K RECEIVED BY p TE PERMIT NO. <br /> SH <br /> . EM 13.24 tREV.r�n 51 t/ / �� �. / � f /3 <br /> fm 14.25 <br /> f <br />