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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 'Es 4 <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 No 'LuaI - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ND tA-e F <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 Address41 <br /> Lot Size/Acreage = �X <br /> Owner's Name Address (hone <br /> ��� License No. Phone +ter <br /> Contractor ===__f Address , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well El <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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ — Dia. of Well Casing <br /> C.1 Domestic/Private CI Gravel Pack C1 Tracy Type of Casing_ r Specifications <br /> I'1 Public 1-1 Other fl Delta Depth of Grout Seal E Type of Grout <br /> 3 <br /> I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done . U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sesling Material.& Depth <br /> Depth Filler Material & De th <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 RE k I I EST C 0 n <br /> _ I i s tem permitted if public sewer is, <br /> ..z a in 200 feet.1 <br /> installation will serve: Residence— Commercial_ ther ]; <br /> Number of living units: Number of bedrooms Permay 7�! e axphd w1thout+ <br /> Character of sail to a depth of 3 feet: a$d table depth <br /> SEPTIC TANK. 0 Type/Mfg pace , Na-Compartments <br /> PKG. TREATMENT PLT.C7 by F-Mift �'"`L �1 16 et od of Disposal <br /> f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well r Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature I <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant <br /> ttlmfust call for all required inspections. Complete drawing on reverse side. I <br /> Signed //lam 9 -_ Title: _�O_ ' .J __ _ Date: ? <br /> OONLY <br /> Application Accepted byDate Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all aopies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Serviaes <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED Fi RECEIVED BY DATE PERMIT'NO. <br /> INFO Ja9 +l <br /> . EH13-24IREV.F/HSI eti <br /> ��®0 ��� sem• <br /> EH 14.26 <br />