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€ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 3 T ENVIRONMENTALHEALTH DIVISION <br /> 445 N SAN JOAQUIN, pHONE (2CA )468 <br /> 9520]420 <br /> p O BOX 2009, <br /> PERMIT E%pIRES 1 YEAR FROM DATE ISSUID <br /> ?� (Complete in Triplicate) <br /> glade to San Joaquin County for a permit to construct and/or install the work herein u ationsdof Sans <br /> Application is hereby .to San Joaquin <br /> San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regula <br /> application is made in comp � f <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> City! <br /> Job Address <br /> Phone <br /> Address <br /> I Owner's Name(• �7� <br /> rr. License No. Phon <br /> Address Out of Service well ❑ <br /> Contractor WELL REPLA EMENT F DESTRUCTION Ll <br /> NEW WELL ❑ OTHER ❑ Monitoring well C7 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> ! PUMP INSTALLATION ❑ DISPOSAL fLD. PROP. LINE <br /> ` SEWER LINES ----- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK ^��- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION �� <br /> z.- y r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. � CONSTflUCT10N SPECIFICATIONS _ Ria. of Well Casing <br /> C1_Manteca _Dia.-of Well Excavation <br /> f} Industrial <br /> p�n Bottom_ a..-- r'� � + - v Specifications <br /> ' ❑ ra 1 ap_i�7al��;l�L ► <br /> (:I Domestic/Private ❑ Gravel Pack Type of Grout <br /> !7 Other ` . l i1 Ve1ia Depth of.Grou�rvtS�Tera�hi p <br /> I'1 Public Q H�.'f iMPIM t 4�i1� �T <br /> IIrrigation Approx.-Depth NM &WOOD, �K alone Q <br /> Repair Work Done L7 Type of Pump Sealing Material & Depth '` <br /> Well Destruction O Wu. { i <br /> t Filler Material i Depth <br /> Depth <br /> r_ 1 y available within 200 feet.] y <br /> TYPE OF SEPTIC WORK: NEW INSTAgLLATION I I REPAIR/ADDITION F DESTRUCTION i 1 tN6 septi system permitted if public sewer is <br /> - e <br /> Inst will serve: Residence- Commercial Other <br /> / <br /> Number of living units: Number of bedrooms 1 <br /> t � Water table depth <br /> Character of soil to a depth of 3 feet: A Capacity •— No Compartments <br /> SEPTIC TANK © Type/Mfg, Method of Disposal, <br /> PKG. TREATMENT PLT. C7 <br /> t v Foundation_ -= Property Line N c <br /> f Distance to nearest: Well`` - <br /> .- O <br /> Total length/size <br /> LEACHING LINE L) No. & Length of lines Properly line 10 — <br /> Foundation _ /Q-- <br /> FILTER BED ❑ Distance to nearest Well Cly* <br /> Cy Number <br /> SEEPAGE PITS 11 Depth Size i ��� / } <br /> ou dation - 6+�'A--- Prape <br /> Well rtY Line - ll <br /> SUMPS LI Distance to nearest: _ � f X <br /> U M x <br /> ] DISPOSAL PONDS IE <br /> Tow oaquin county ordinances, state laws; and <br /> i hereby certify that Ihave prepared this �� t��':l�UtfL��ri 1G�.a <br /> F rules and regulations of the San Joaquin LourifY ;"f the work for which this permita's issued, I shall not <br /> Home owner or licensed agent's signature certifies a s ornia." Contractor's hiring or sub-co`ntraciing signature <br /> employ any person in such manner as to become subj e I shall employ persons subject to workrriari's`compensa <br /> certifies the following: "I certify that in the pertormanc@ wT <br /> rAZ <br /> tion jaws of California." "}g <br /> The applicant m II for all r Hsps tuns. Complete drawing on reverse side. <br /> Dots: <br /> Signed <br /> •, ._ �.. __,� FO.�R DEPARTmtNT-USE"ONLY`" �i <br /> Date - Area "] <br /> Application Accepted by <br /> Dr <br /> 30 <br /> I Date at inspection by <br /> Pit or Grout Inspection b <br /> Additional Comments: fy g C <br /> i Applicant - Retur all copies to. <br /> Envirvnmentalan joaquin vHealthuPermit/Servicesv cel <br /> [if GL <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 s ` . <br /> CK RECEIVED BY DATE PERMITII'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO i+ 0 0 <br /> . EH!3-94011EV.I/R5) V <br /> EH 14-20 <br />