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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 L 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. 51+9 and 1862 and the Rules e.nd Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 64ACity Lot Size/Acreage <br /> Owner's Name r 1 Address lrl -- Phone <br /> oe <br /> Contractor �6 _eo Addresf– �x v License No. PI)one 4 <br /> TYPE OF WELL/PUMP: NEW EI L 0 � WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Se <br /> r"yice Well Cl <br /> PUMP INSTALLATION C�SAN JOAQUINsWMq*I? �HBII.IC HEALTH SZ E51 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW MFRI§'N-M _H <br /> ENTALEAi9 3S �'�SW.N-- -- PROP. LINE VJ <br /> FOUNDATION AGRIC TURE,WS T:HER-WE PITS/SUMPS <br /> INTENDED USE TYPE ELL PROBLEM AREA CO STRUCTION SPECIFICATIONS <br /> O <br /> I f'l Industrial ❑ Open-Bottom"' a—Mantec'�-T -T N5 —Dia ell':Casing- <br /> f.1 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy �yp'e oft-tias g._1:3 Specifications <br /> I'1 Public i-I Other (��i�frlyy�/D►elyyt����I$IflIQ I�p ib�Tt �y �`t r?Xa - Type of�irout__ _ <br /> I I Irrigation k Appra>t. Depth `�9`i%4tt�r1'III:LTtda1JAU3A 1r1 MW <br /> Repair Work Done L7 Type of t H.P. _ State Work Done,, <br /> Well Destruction ❑ Well Diameter Sealing Material &Depth' _r- I- <br /> t Depth Filler Mater6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/AOIYION DESXRUCTION i I INo septic system pe4rmitted if publicIr <br /> 1 available within 200 feed.. v+ \ <br /> Installation will serve: Residence Commeccil Lamer /ni <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feeti - - Water tableaedth•�. 91 <br /> s• <br /> SEPTIC TANK. ❑ Type#Nf g v ✓ Capacity ' No. Compa me+nts/ M""� "" i <br /> ` Method of Di sal',/ ~ } <br /> PKG. TREATMENT PLTi❑ r 'moo � s <br /> Distance to nearest: Well Foundation Property Line ! <br /> t71t + <br /> LEACHING LINE No. & Length of lines a `f .s '° Total length/size— <br /> FILTER BED Cl Distance to nearest: Well, �� �hndatior Property Line 4–=} <br /> r"T <br /> rv j <br /> SEEPAGE PITS 11 Depth ___St ize Number '-� p+• +Dfi� L <br /> SUMPS Distance to nearest: ell �a r Fou dation �Or Property Line �o--- l <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and hat the work wilt be one in accordance witli San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County S'i r I <br /> Home owner or licensed agent's signature cenifies the fol owing; "I certifX Jhat in the performance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject o workman's compe ation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the-work-for whir s permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I I <br /> Theapplicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X— - _ _ Title: i Date: [ .CF •g <br /> FO DEPARTMENT USE ONLY r <br /> � ! —a — z. v 1S <br /> Application Accepted by Date a <br /> Pit or Grout Inspection by ate Final Inspection by Dat <br /> SAN JOAQUIN COUNTY- LIC HEALTH SERVI <br /> Additional Comments: SAN <br /> 1ENTAE H•r: r, _— <br /> r <br /> Applicant - Return alll copies to: San Joaquin County Puj4icAc,-$ <br /> a vi & ll!Y1 1 <br /> i Environmental Health 52 11445 N San Joaquin, P on, A D 1 <br /> FEE RECEIVER_B <br /> AMOUNT l]tlE,. AMOUNT REMITTED CIC Y OATE._,� __PERM17_NO._ <br /> . EH 13•241REV,I/R5r <br /> EH 11.2E __- <br />