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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> '1 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 lnodWliance with San Joaquin County Ordinance No. 549 and 1862 and the es and Regulations of San <br /> Joaquin County Public th Services. 42 <br /> i ,®� , Size/Acreage <br /> Job Address �J <br /> Owner's Name ddress <br /> ~ Phone <br /> Contractor ��.- <br /> � License No46 1 3 Phone <br /> TYPE OF WELL/PUMP: NCD <br /> EW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITStSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> Type to Domestic/Private Cl Gravel Pack ❑ Tracy T Yp of Casing-- Specifications <br /> I'I Public 1=1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> 4 I I Irrigation ,,,.—, Approx. Depth t I y5tern Surfs <br /> eal Installed by Q <br /> l Repair Work Done t� Type of Pump H.P• State Work Done <br /> ILII Sealing Material & Depth �) <br /> Well Destruction � Well Diameter <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 1 allo septic <br /> system permitted if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> } Number of living units: Number of bedrooms <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity Na. Compartments <br /> PKC. TREATMENT PLT.C7 Method at Disposal <br /> tt Distance to nearest: Well Foundation Property Line ^ ' <br /> k Total length/size <br /> A <br /> LEACHING LINE Ll No. & Length of lines <br /> FILTER BED 0 Distance to nearest:, Well Fo dation Property Line <br /> SEEPAGE PITS 11 Depth — Size Number <br /> e SUMPS [1 Distance to nearest: Well Foundation operty 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 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 w rkman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the follow' c ify that in the perfor ante of ork for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion laws of Cal' r " <br /> The applican t r t' d Title: on re rs si Date: / <br /> p <br /> Signed <br /> FO EPARTMENT USE ONLY r�} <br /> Application Accepted by Date �' Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> 4 <br /> Additional Comments: EE <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> i INFO / <br /> A111A> <br /> f EN 3.24 tREV.I x 5) Joe <br /> t�o �j <br /> EH 114.26 r <br />