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1 U/L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 KA-J015 <br /> P 0 BOX 2009, STOCKTON, CA 95201 �� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' g�� �. ®. I I ' Com ate i T,r 'p icate) It�S- Ikv- Z� g <br /> ` Application ie hereby made to San Joaquin ounty for a pe t to const et and/or install the work herein described. This <br /> application is made in cotepliance with san Joaquin County Ordinance No. 549 and 1862 and the Rules and egulations of San ` <br /> Joaquin County public health Services. �$rgru/T7�J'�Y $i� - F4r4"ry� <br /> *20 amts. S n&TrT 070 14t rV Z6 <br /> Job Address o 60 rhls ", City [Ji40a=^1 Lot Size/Acreage <br /> 76&-t;s4 77�N,9X-+9 `�-^ 1 <br /> Owner's NameDA-Ams" Zo""TY /ms s p.0. Y3CaX +� s _- Phone e0 7- � i� <br /> t <br /> Conlraclor�� N� i�dress Z�Z�� ig. MZgZZ S7 License No.S�/2ZZ6$ Phone tf s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION e <br /> PUMP INSTALLATION•❑ SYSTEM REPAIR C] OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .09-itt, <br /> FOUNDATION AGRICULTURE WELL OTHER WELL —*FT�T. M7- 13 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `M 3O /39Gr <br /> L� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation U <br /> EI Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ _Spee0tee64-. <br /> I'1 Public (.1 Other n Delta `Depth of Grout Seal T)!IFSr /O+, <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 <br /> Well Destruction ❑ Well Diameter Sealing Material b Depth , <br /> Depth Filler Material 6 Depth �" � <br /> ~TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I No sspii <br /> availably mt.1 r,I*i--A� 6 <br /> F Installation will serve: Residence_ Commercial Other Ems+ W4,dcov. , Cs <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal h M <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. b Lengthoflines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Il Depth t Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property 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 J <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, t shall not f <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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed x, Title: Date: /'/Z ~ M - <br /> F. D RTMENT USE ONLY J <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> Applicant - Return all copies -to. San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> ,.a :445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> WO CASH ry <br /> a EN 324[REV.UA51C f�/` 0 <br /> EH 114.26 <br />