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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> f 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 Public Health Services. <br /> Job Address 90 1/ /0/6 V-/1 0 _ _ City, -`�'" t�`y�Lot Size/Acreage <br /> T /' /�t'7 �1de .IS� _ <br /> Owner's Name / Address' U,.. __,.,. �T�r/ex 77L <br /> 9 ( / Phone <br /> Contractor <br /> 6d'it /< ✓T>�i� Ze Lict6�No. Phone <br /> TYPE Of WELL/PUMP; NEW WELL 0 WELL.RE.PLACEME,NT ❑ DESTRUCTION t of Service We11� <br /> PUMPINSTALLATION CJSySTEM REPAIR 111OTHERp Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD. PROP, LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> F1 Public 1-1 Other I-1 Delta Depth of Grout Seal Type of Grout t <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by O <br /> Repair Work Done 1J Type'of Pump "�� H.P. St to Work Done <br /> Well Destruction A Well .Diameter � Sealing Material a4 Depth yy� ri`/`CTt <br /> , <br /> DepthFiller Material & Depth <br /> OF SEPTIC WORK: NEW h INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is V ' <br /> available within 200 feet.) <br /> Installation rve: Residei ce�.—. Commercial— Other <br /> f Number of living un Number of bedrooms <br /> f Character of soil to a depth t: Water table depth <br /> t SEPTIC TANK. ❑ Tylpe/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to rest: Well o •eq,�.�. Property Line � <br /> LEACHING LINE C1 I. & Length of lines Total length/siz�Line <br /> FILTER BED Distance to nearest: Well Foundation Propert <br /> 4 <br /> SEEPAGE S 11 Depth Size Number - <br /> SUMP L1 Distance to nearest: Well Foundation Property Line <br /> R POSAL 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 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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Calif la. n. .. ..• +.. �a -- . <br /> The applican ca f a7, /0 <br /> s ctions. Co Eete drawing o v rse'side. <br /> Signed Title: T Date: <br /> I DEPARTMENT USE ONLY �l Q <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date r}� <br /> Additional Comments: " s <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 <br /> INFO ►A,MOUNT DUE AMOUNT REMITTED CASH CEIVED BY ATI? AERMiT'NOO. /y/ <br /> i EH t4.25 EH 13-24(AIV. r n si WJ> tJ�. [�' . / 07 V V1 I <br />