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Y� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <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 <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 Pgplic Health Services <br /> �S <br /> Joh Addressd_J--- City Lot Size/Acreage <br /> { Owner's Name Cell fjk� r 0m e-- Address �eA*,� Phone <br /> Contractor Ades License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia7-6f Well Excavation Dia. of Well Casing <br /> C-1 Domestic/Private Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I"I Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> i I I Irrigation —.Approx. Depth t I Eastern: Surface Saul Installed by <br /> f <br /> Repair Work Done U Type of Pump ; H.P. Z State Work Done ! S� <br /> Well Destruction ❑ Well Diameter sealing Material & Depth <br /> Depth - ]�— Filler Material & Depth <br /> OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIAlADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation wi Residence Commercial— Other 1 <br /> Number of living units: Number of bedrooms <br /> 3 Character of soil to a depth of 3 fee. Watar table depth <br /> i SEPTIC TANK., IJType/Mfg Capacity No. Compartments " <br /> PKG. TREATMENT PLT. C7 ` Method of Disposal <br /> I Dista to nearest: L Well o 'on k _ Property Line <br /> 3 <br /> LEACHING LINE No. & Length of lines Tota /size <br /> 1 FILTER BED ❑ Distance to nearest:— = Well Foundation - Property <br /> k <br /> i SEEPA PITS I 1 Depth Size Number <br /> f SU LI Distance to nearest; Well Foundation Property Line <br /> D POSALPONDS ❑ <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 licensed t'a 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 i .ch nner as to became ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature. <br /> certifies the foil? ' g: "I co ify that in the pe ma ca p1 the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Ca'omla." <br /> The appfican mus ca all r s1 a drawing o r side. <br /> .� .. <br /> L <br /> Signed X Title_ 9 i 4 Date: Y <br /> 4. &W <br /> EPARTMENT U E ONLYApplication Accepted byR Date IJv� (/ Area <br /> Pit or Grout Inspection by Date Final Inspection b <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 RECEIVED By DATE PERMIT N0. <br /> INFO CASH <br /> . EH13.711REV.1/N51 <br /> EH 14•35 r !/ <br />