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it <br /> I` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 F <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I� PERMIT EXPIRES I YEAR FROM DATE ISSUED !I <br /> (Complete in Triplicate) <br /> E work <br /> Application is hereby grade toan y hu nCJoaquinor a Countyrmit to OrdinaneenNo. 549 ando1862sand theeRules andeRegulationsdof Sans <br /> application is made in compliance <br /> Joaquin County Public Healtb'Sery r Lot Size/Acreage <br /> �s2 3� Cilc'l <br /> Job Address Z �23� f <br /> Phone 1 <br /> Address ! <br /> Owner's Na t 321 Z - <br /> ! 7 License No Phony j <br /> Address { <br /> Contract WELL REPLACEMENT C7 DESTRUCTION Cl Out of Service Well ir1 <br /> NEW WELL Q OTHER O Monitoring Well ❑ <br /> TYPE OF WELL/PUMP. !i SYSTEM REPAIR ❑ <br /> PUMP-'INSTALLATION ❑ PROP. LINE <br /> DISPOSAL FLD. <br /> _ o t <br /> SEWER LINES —�- P1T5ISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- AGRICULTURE WELL OTHER WELL,�— i <br /> FOUNDATION �----- • . ' <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing"- a <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> [� Industrial Specifications—+ <br /> ❑ Gravel Pack ❑ Tracy Type of Casing_ Type of Grout <br /> I'l Domestic/Private F1 Delta Depth of Grout Seal i <br /> {"1 Public Cl Other <br /> Apprax. Depth 4 I Eastern Surface Seal Installed by r <br /> I 1 Irrigation H P State Work Done <br /> Repair Work Done U Type of Pump <br /> k Sealing Material 3 Depth , <br /> Well Destruction ❑ Well Diameter. ---- i11er Material i Depth <br /> Depth <br /> ., available within 200 feet.I :. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR ADDITI.ON.I I DESTRUCTION l I lNo+septic system permitted if public sewer is <br /> installation will serve: Re 'de;nce....� Commercial y Otho ,f <br /> Number b room '\. <br /> Number of living units: Water table depth. <br /> Character of soil'to a depth of 3 feet: Opacity fa/_�r1 O: '-"`1;fo. Compartments <br /> SEPTIC TANk ' o` Y Typel.Mfg "y"�' <br /> i -. . ,JK. qtr i Method of Disposal .y <br /> PKG.;TWEATMil T'PLT. s Property Line -- <br /> Distance to f6earest: 1"WeH - foundation' f <br /> Z X.2 <br /> A`TFtal Is <br /> (LEACHING LINE S QO_&xengthiof lines . <br /> Foundation ��, — Property Linef <br /> G1, Distance to nearesft:, Well t <br /> FILTER BED s , �` <br /> t r Number <br /> pepth Se undation;.^ <br /> Property Line <br /> SEEPAGE PITS ll <br /> SUMPS L^—Distanceonearest:/ Fo -- <br /> DISPOSAL PONDS ❑ „ <br /> I hereby certify that I have prepartad this-application and-that-the work wilLbe e n,a cordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatiani of the San Joaquin County'( % g, work for <br /> Home owner or licensed agents sr9as a beco if ies the-f(e'stlto workman'srtcompensat on IaewsQof'California,\rm8nce of e Contractor sthiringr or sub-cont ermit acis $nglsignlatu6e <br /> j employ any person in such manner <br /> certifies the faliawing�"I cetify that in the performance of the work for which this permit is!ssued,J�sh�all employ persona subject to workman's compensa <br /> tion laws of California." r-- <br /> The applicant u all for ,Il fe inspections. Complete drawing on reverse aid !+' <br /> Date: QnCL2 <br /> Title: <br /> k Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date Z Area <br /> Application Accepted by. I� �_ Date� - <br /> + � Final Inspection by <br /> Pi or Grout Inspection by Date <br /> 01 <br /> r <br /> Additional Comments: <br /> i Applicant •- Returnlilall copies to: San Joaquin County Public Health Ser ices <br /> Environmental Health Permit/Services <br /> �. 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> l INFO <br /> . EH 13-24 tAcv.I I a W r d� <br /> EH 14.25 <br />