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- - ---------- <br /> SAN <br /> ---"-SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 Sen <br /> Joaquin County Public Health Services. <br /> c <br /> Job Address City�__�TE 41 Lot Size/Acreage <br /> Owner's Name _ 7� M1����_ Address Phoria � <br />' Contractor Address / �License N _Phone <br /> EaL <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service He11 ❑ 'i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 4F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f 7 Industrial ❑ Open.dottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> to Domestic/Private ❑ Gravel Pack L) Tracy <br /> f'#.Public f_1 Otherlr n Delta <br /> Depth of.Grout Seat Type of Grout <br /> I 1 Irrigation <br /> —.Approx. Depth I I Eastern Surface SealAnstalled.by " <br /> Repair Work Done L3Type of Pump H.P. State Work Donef ` <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �_ _ <br /> Depth r4 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR JADDITIDN;1 1" DESTMUCTION I ! {No sept s stein 1 j <br /> P Y permitted if public sewer is: <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other f <br /> c <br /> Number of livingunits: v ;- <br /> �� Number of bedrooms <br /> Character of soil to a depth of 3 feet: ��ti,' A Water table.depth <br /> SEPTIC TANK. ❑ Type/Mfg - <br /> Gal achy 2 No-'Compartments - r <br /> PKG. TREATMENT PLT,❑ <br /> Method of Disposal I <br /> Distance to nearest: Well Foundation-. ' <br /> �, _Property..line 0�_. <br /> LEACHING LINE SIC No. & Length of lines �7— <br /> =- -Total length/size .; <br /> FILTER BED ❑ Distance to nearest. Weil/g; !! " Foundation Property Line <br /> j f <br /> a <br /> SEEPAGE PITS 11 Depth Size Number. <br /> SUMPS LI ..Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Ir t I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats lawi, 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 signatuld <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 compens�_ <br /> tion laws of California." <br /> The applicant must call for aI required 'nspectio s. Complete drawing on reverse side. y <br /> Signed Title: Date: — ey <br /> F DEP MENT !f ONLY <br /> Application Accepted by Date .� a ` r� <br /> Pit or Grout Inspection by Date Final Inspection Dat Q <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services F <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, /CA 95201 ~` <br /> r <br /> FE AMOUNT OUE AMOUNT REMITTED I <br /> INF K ECEIVED BY JA ATE PERMIT'NO, I �� <br /> EM-1��7�"IRtY.r i x 51 - — - — - - - /'" - _ -^^_�• - - - -- *----�� - - "•--�•- � - --..�" <br /> EN 14.26 I Y <br />