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�k <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 'I <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PL DC �'i (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 HealtW Services. <br /> Job Address Gity L 'r�ize/Acreage <br /> Owner's Name d�MrA &.or d!A_/A26g Address C _ Phone <br /> 1 e' <br /> Contractor D Address �� License N Phone er' <br /> TYPE OF WELL/PUMP: p NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION L1Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C� <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 ❑ Open Bottom .`+ ❑ Manteca "' Dia�af Weld Excavation Dia. of Well Casing <br /> b ' Specifications <br /> Domestic/Private g ❑ Gravel Pack-- -F C7*Tracy Type of Casing_ <br /> Public T Sa Otei C <br /> hl Delta Depth of Grout Seal Type of Grou <br /> I I Irrigation _Approx. Depth i Eastern Su a Seal Installed by <br /> Repair Work Donef7 Type of Pump H.P, State Work Dan ([� <br /> Well Destruction O Well Diameter Sealing Material 6 Depth V� <br /> a <br /> Depth it Filler Material & Depth i r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION,l I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: ilNumber of bedrooms <br /> f• 5 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments V)Vv 111 <br /> PKG. TREATMENT PLT, 0 F Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE. Cl No'M& Length of lines Total length/size <br /> FILTER BED ❑ Distkance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS✓ 11 Depth Size Number <br /> SUMPS I` LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 r <br /> Home owner or licensed agent's signature certifies the following; "l 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 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 appli must all for all required in coons. C plete, drawing on re <br /> '­ side. ; <br /> ._. - <br /> � ' _ , <br /> Signed � Title: Date: i <br /> h FOR DEPARTMENT USE ONLY <br /> i} <br /> Application Accepted by �� `f _ ^r Data L res <br /> Pit or Grout Inspection by ` <br /> Additional Commeri � Oate Final Inspection by VV r <br /> Date <br /> is— !I t ` <br /> .v <br /> Applicant ;Return allioopies to: San Joaquin County Public Health Services <br /> Bn,vironmental Health Permit/Services <br /> # ► I� ~� 445 N`SAn Joaquin, P O fox 2009, Stkn, CA 95201 <br /> FEE f AMOUNT DUE AMOUNT REMITTEDAV <br /> 7 <br /> K RECEIVED BY DATE PERMITNO. <br /> INFO <br /> 4 M <br /> . EM 13-24 IREV.1/x51 /W 60 <br /> EH 14.3E <br /> II <br />