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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 madeto Ban 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 Address, -�ylr4 A4 10uN/C City_ C/� o Lot Size-/Acreage <br /> Owner's Name _1111 XX V /�/YO�s°TSO Address AJrYV0 Al, "(/%G P Phone �✓ �'�� <br /> Contractor 'SQ/U Address 1CO09 w!� rj y e` f"I'0' License No.!KY`47 Phone <br /> TYPE OF WELL/PUMP: i�. NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SE�IC 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 /> r _ <br /> ` ❑ Industrial ❑ Open Bottom E-] MantecaDia. of Well Excavation Dia. of Well Casing <br /> Cl DomesticlPrivate ❑ Gravel .Peck ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout [ <br /> t I Irrigation __�IApprox. Depth t I Eastern Surface Seai Installed by <br /> ` <br /> RepairWorkDone L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well,: Sealing Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR1ADDiTION I k DESTRUCTION i I (No septic system permitted if public sewer is <br /> a :11, � available within 200 feet.l <br /> I Installation will serve: Residence Commercial_ Other �e j �I <br /> g �I Number of bedrooms - <br /> Number of living units: ' <br /> Character of soil to a depth of 3 feet: J- _4 Water table depth <br /> SEPTIC TANK Type/Mfg OoX C10A7` Capacity t coo No. Compartments 2 <br /> { PKG. TREATMENT PLT, Ll 11! Method of Disposal <br /> Distance to nearest: Well �Oa SF Foundation '� Property Line <br /> 4 .. <br /> LEACHING LINE 10 No. & Length of lines � � �' � Total length/size ii d n <br /> FILTER BED ` ❑ distance to nearest: Well 6�G� Foundation �S� Property Line <br /> J!. <br /> I' SEEPAGE PITS " ph Depth ' Size 6�� ®iii Number .3- <br /> SUMPS :' LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <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 Sari'Joaquin County <br /> Home owner or licensed agent'atsignature 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 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." II` <br /> The applicant must call for all r Iequired inspections. Complete drawing on reverse side. <br /> Signed X__ Title: Date: <br /> � t f <br /> FOR-DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> � <br /> 4Dft or Grout Inspection by Date Final Inspection by Date <br /> I Additional Comments: <br /> d <br /> r Applicant - Return all copies to: San Joaquin County'Public Health Services - <br /> f Environmental Health Permit/Services <br /> I 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO rc CASH <br /> I . EH 17.24 IREV. <br /> EH 14.26 <br />