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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH .DIVISION . ` <br /> a. 445 N SAN JPH <br /> OAQUIN, ONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 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. 549 and 1862 and the Rules and Regulations of San 1 <br /> Joaquin County Public Health services. <br /> r <br /> City � Lot Size/Acreage <br /> Job Address <br /> Owner's Name h4U <br /> Address Phone f <br /> Contractor w r <br /> ULC Aar"-��s -� - License No. ' Phone .. . a <br /> dress <br /> TYPE OF WELL/PUMP„ NEWWELL.❑ _ , WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well 0 <br /> PUMP INSTALLATION 13 SYSTEM REPAIR ❑ OTHER G <br /> Monitoring-Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> C7 Domestic/Private <br /> ❑ Grave! Pack 0 Tracy Type of Casing. <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> l <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ th <br /> `Sealing Material A7Di�TH <br /> Well Destruction ❑ Well Diameter : r <br /> Depth -�`---»tiller Material;& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is t <br /> available within 200 feet.) f <br /> Installation will serve: Residence` Commercial— Other � "1 % <br /> Number of living units: J__ Number of bedrooms_1zi-1 <br /> r, <br /> Character of soil to a depth of 3 feet: W. '-Water table depth <br /> SEPTIC TANK x ❑ Type/Mfg �` Capacity No. Compartments <br /> ZZ <br /> PKG. TREATMENT PLT.0 s��� Method of Disposal <br /> Distance to nearest: Well :Cvfl�4�Foundation C26 - Property Line <br /> of rc;r _. �Q i Tot I len th/size <br /> LEACHING LINE - -�---� rf�io:,,&Length of lines'"1�� _ ��- r 9 <br /> An' <br /> # �. <br /> FILTER BED Cl Distance nearest:' ; Wel!> Foundation Property Line <br /> Leo -,-3, )G /11 CIO <br /> SEEPAGE PITS I l Depth. _ � _-- Sizer - -Number <br /> SUMPS X Distance to nearest: 'Welt_�--- Foundation/lJt�F7Property Line <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 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 shalt not <br /> employ any person in such manner as to become subject to workmarN 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 applicant must call for all requu d inspections. Complete drawing on reverse side. /} <br /> i r Title: Date! C�`� <br /> Signed <br /> FOR DEPARTMENT USE ONLY ) <br /> Application Accepted by r Date ! « Area <br /> Pit or Grout Inspection by = Date Final Inspection by Date �Z y <br /> Additional Comments: eg-ARdA <br /> f Applicant - Return all copies to: San Joaquin County Public Health Services UU <br /> Environmental Health Permit/Services <br /> 445 -N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> i FEE .- AMOUNT DUE AMOUNT REMITTED' CK RECEIVED BY DATE 1 PERMIT'No. <br /> INFO <br /> II - �4[• L 117 <br />' EH t3-Z4 iREV.i l x si . <br /> EH 14.26 _ <br />