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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 /> 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 frith San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> i I f7+ �1+ 1City 5 Xk) Lot Size/Acreage <br /> Owner's NameDfr)lJrif 5 Address 99 Phone 701 <br /> Contractor <br /> �(GSG{/ta �GGIrn Adress License No.,J] $_3_'2Y_Phone <br /> TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT M DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well ❑ <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 /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other 1 n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth t_I_Eastern Surface Seal Insialled by. \ <br /> Repair Work Done L7 Type of Pump H.P. State Work Done T <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material ADepth <br /> Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION li lNo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence VCommercialy_ Other R <br /> Number of living units: Number of bedrooms .w.� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> _ Distance to nearest: Well Foundation — Property Line <br /> LEACHING LINE ❑ 'No. & Length of lines Total length/size , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS ❑ <br /> ha <br /> I hereby certify that 1 have prepared this application and tt 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in thWperformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." .I <br /> The applicant "11ca I for equire ins ctions. Complete drawing reverse side. 9 <br /> Signed X Title: T Date: +�c D <br /> aP:T�ARTMENTUSE ONLY ! c <br /> Application Accepted by th INMU26A Date 1�1 Area <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County'Public Health Services <br /> Environmental Health Permit/Services <br /> i y 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FES:. AMOUNT DUE � AMOUNT REMITTED CASH RECEIVED BY D E PERMIT'NO. <br /> INFO <br /> . EH 1321 IREV.1/ 51 <br /> �59 <br /> f FH 14.26 c L <br />!t f <br /> t _ <br />