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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> C P 0 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 <br /> Joaquin County Public Health Services. <br /> Job Address City �LiV Lot�6 Acreages <br /> Owner's Name�& t!y��,�i e,4 n �. Address J2 �/l�f �iU 4f��Phone S <br /> i <br /> Contractor NIU«S�t t '104, s p�1� Phone <br /> __.- _ - ' A-9ress � j License No. <br /> TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of ServiceWell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR>' OTHER ❑ Monitoring well . � <br /> DISTANCE TO NEAREST: SEPTIC TANK &� SEWER LINES DISPOSAL FLO.17S y PROP. LINE/60 <br /> .—..FOUNDATION_— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS" <br /> n Industrial 11 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> J7il<Domestic/Private ® Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> FI Public f-1 Other f-} Delta Depth of Grout Seal Type of Grout 1 <br /> I I Irrigation _ �[ �..Approx. Depth f I Eastern_ Surface Seal Installed by <br /> Repair Work Done iC1. Type of Pump H.P. State Work Done i�¢ Ex eP 9rr <br /> Well Destruction p Well Diameter Sealing Material & Depth <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Numtie►of`bedrooms <br /> Character of soil to a depth of 3 feet: Water I <br /> SEP <br /> PKG. <br /> PKG T YANK ❑ Type/Mfg Capacity No. Co t BB CD <br /> TREATMENT PL7. ❑ Methos f1 <br /> Distance to nearest: Well Foundation Property Line ��(� `� 1 <br /> ,. ' <br /> LEACHING LINE Cl No:& Length of lines Tata! length/sizeSl� 1aP <br /> r <br /> FILTER BED —'Distance to nearest: Well Foundation i l ,� tF'CI' h' <br /> Pro rt i <br /> �tw�� u� <br /> E,NVINUII�T`{ i1LIk <br /> SEEPAGE PITS 1.1 depth Size Number <br /> SUMPS L) Distance to nearest: Well Foundation --_ _ Property Line <br /> 'DISPOSAL PONDS- d <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`ta�is;arida <br /> rules and regulations of the San,Joaquin County.. _ F - _ _ _ <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 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." I <br /> The applicant must call for all r uired ins <br /> pe ions Complete drawing an reverse side. <br /> Signed J, <br /> Title: Date: s Z <br /> R DEPARTMENT USE ONLY <br /> t <br /> Application-Accepted by I �+ / <br /> Date e_a <br /> Pit or Grout inspection by ate Final Inspection b Date <br /> Additional Comments: pp <br /> Applicant - Return all copies to: San Joaquin County Public Health Services I <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> t INIFO �+1 �/7��� -CASH RECEIVED 9V DATE Ch1 PERMIT N0, <br /> • EH 17.2 IRtY.lira) /C �v �/ Z, t Iv' iJ� <br /> EH 13.2a <br /> ' t <br />