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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 0 BOX 2009, STOCKTON$ CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> # or a permit to construct and/or install the work herein described. <br /> Application is hereby made to San Joaquin County fThis <br /> application is made in compliance With San Joaquin County Ordinance No. 51+9 and 1862 and the ]Rules and Regulations of San <br /> '.s Joaquin county Public Health Services. ; <br /> City Lot Size/Acreage <br /> Jqb Address <br /> w <br /> ' .S/ �8' <br /> Owner'sSHfama ©N Address _ Phone <br /> Contractor <br /> Address L-)cense No. f'hotQ��" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RILPLACEIVENT M DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION CSYSTEM""REPAIR---❑^'r}' --_—OTH.ER itorIng Well ❑ <br /> DISTANCE70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <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 Wail Excavation - Dia. of Well Casing <br /> CI bomesfic/Private ❑ Gravel Pack Cl Tracy Type of Casing_ Specifications <br /> I I"1 Public 1-1 Other i-1 Delta Depth of Grout Seal Type of Grout <br /> I f Irrio$[ion' _Approx. Depth 11 Eastern Surface Seal Installed by <br /> _ <br /> z f Repair Work Done CJ Type of Pump H.P. State Work Done , <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth � <br /> Filler Material & Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO I DESTRUCTION l (No septic system permitted if public sewer is 1 '� <br /> available within 200 feet.) <br /> Installation will serve: Residence_X Commercial_ i Other <br /> Number of living units: Number of bedrooms ^ <br /> Character of soil to a depth of 3 feet: Water table depth Js <br /> ® <br /> .a SEPTIC TANK- 0 Type/Mfg � � -- CapacityNo. Compartments `Z- <br /> �— <br /> ' PKG. TREATMENT PLT. El Method of Dispo i. <br /> Distance to nearest: Well _ Foundation l r— Property Line cl <br /> tknLEACHING LINE ❑ No. & Length of lines '� D <br /> Total length/size' <br /> FILTER BED Cl Distance to nearest: Well-! �� Foundation Property Line' <br /> i; <br /> kF <br /> SEEPAGE PITS Depth Sire f Number <br /> k: SUMPS 0 Distance to nearesY'�,, Well _�.`L� Foundation Property tine: <br /> DISPOSAL PONDS ❑ <br /> 4r I•hereby certify that I have prepared this application and that the work will be done in accordance with San 7oaquin,county ordinances, state laws, and <br /> k <br /> rules and regulations of the San Joaquin County 1 r <br /> Homo 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 /> y.p <br /> employ anerson in such manner as to become subject to workman's compensation laws of- California." Contractor's hiring or sub-contracting signature , <br /> certiiiea 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 /> r r <br /> The applicant mu call f r all re )raft) s ctions. Complete drawing on reverse side. I I <br /> Signed X Title: <br /> i <br /> aR&EPARTMENT <br /> USE ONLY, <br /> €;, <br /> . _v_ <br /> Application Accepted by bate 2� °' Area 2 <br /> Pit or Grout Inspection by Date Final Inspection by / Date�� zS !Z <br /> Additional Comments: v� 01 <br /> 6�t00,01 �MwL �&,w-d" it z5�42r <br /> r + <br /> ;Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT RE TIED CASH RECEIVED BY 9ATE PERMIT"NO. <br /> ° INFO <br /> oui <br /> f EH 17.24(REV.1/M 5) <br /> 4 4H 14"26 ✓ V <br /> 1 rh <br />