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.i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED(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 in 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 /> Job Address s-0 �Q Ve /s ►J�-/— City Lot Size/Acreage <br /> 9 Owner's Name `r <br /> Address Phone <br /> Contractor <br /> ��r t��Cr Addres License No-��« Pham <br /> tom___ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Rf OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> a r <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> � I'i Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation — Approx. Depth - 'I I�Eastern Surface Seal Installed by ~ <br /> Repair Work Done Type of Pump _ .l_ H.P. State Work Done" GG <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material & Depth 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION l I DESTRUCTION I I INo septic system permit red if public sewer is <br /> available within 200 feet.l ` �r <br /> Installation will serve: Residence— Commercial_ Other "" ? r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water.table depth . <br /> f f. <br /> SEPTIC TANK ❑ Type/Mfg .Capacity ,No: Compartments <br /> k <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ; <br /> 3'a RDistance to nearest: Well Foundation Property Line f <br /> J 5 ti_ <br /> LEACHING LINE `� ❑ No. & Length of lines f Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number ^y <br /> j SUMPS �; LI Distance to nearest: Well Foundation Property Line <br /> k 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 Inot <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, Iemploy any person in such manne <br /> r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 ction laws of Cel' <br /> 1. <br /> The appli t must all for all requir d inspections. Complete drawing on rever ide. <br /> .0 . <br /> Signed X C Title: Date: ` <br /> FOR DEPARTMENT USE ONLY <br /> i f f <br /> Applica[ion Accepted by Data <br /> Pit or Grout Inspection by Date Final Inspection by ZIFIX Date <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE] BY _?A/E PERMI7'No. <br /> INFO <br /> r , EH 13.24 IREV,I/14!3i / <br /> EH r1-2e <br /> y <br />