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AYYL1LA1'1aJiV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> CV06a 4 a�`o� o�j o fW 1.445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 36,�` t�� P O BOX 2009; STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (,Complete„;iii Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> f!'"'0att6n is made in coaplianee with Sen Joaquin County Ordinance No. 549 and 1862 and the Rudee and RetsuaAtsorie Intl Ann <br /> Joaquin County Public Health Sery ces. t <br /> �/ /i �i'`JC/�i71 L/ Lii_� of Size/Acreage 4�� <br /> Job Address , <br /> Owner's Name _ / �) //[� Address Phone / <br /> 04� or <br /> se No.A6Q�hone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIk4 0,96t of Service Well <br /> PUMP INSTALLATIO e, SYSTEM REPAIR O OTHER Monitoring Well-"[]- <br /> DISTANCE TO NEAREST: SEPTIC TANK IM6 SEWER LINES *_ DISPOSAL FLD. PROP. LINE <br /> FOUNOATION AGRICULTURE WELL OTHER WELL PITS/S6IMPS '`— <br /> INTENDED USEPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_7 Industrial // 9pen Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casin <br /> C.I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_. Specifications <br /> I"1 . iblic (A Other f-1 Delta Depth of Grout Seal Type of, t <br /> igation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public r <br /> available within 200 feet.) <br /> Installation will serve: Residence__�_ Commercial Other <br /> Number of living units: Number of bedrooms t' <br /> Character of soil to a depth of 3 feet: <br /> P Water table depth <br /> SEPTIC TANK O. Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest:r }` Well Foundation Property Line `mss <br /> DISPOSAL PONDS O <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 shall not <br /> employ any person in such manner as to become subject to work man's„compensation laws of 01ifor ia.” Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify th the pert the work for Which this permit is issued hall employ arsonst ubject to workman's compenss- <br /> tioh laws of California. <br /> � ��`rX y <br /> The applic wst ca N s �cti s. C 1 wing on raver side. <br /> Sig Title: Date. <br /> 5� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1-3" i L Area <br /> Pit o�i�iroInspection by l f �f'L Date_10-44-7 Findl Inspection by r Data- L 3 <br /> Additional Commentsa V '�✓ ' ( - _ (G'-� , r�0 �G� /7 r�y/ <br /> Applicant - Return all copies to: San Joaquin �ontY Public Health deryices h�✓fwA/'�' J/wy- 64- <br /> s <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> EE OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> • EN t3-24(REV.I i R 51 (� - i” � �' ('tY• (, !Llr <br /> �b <br /> EH 14.20 P N ^'-- <br />