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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> x 445 N SAN JOAQUIN, PHONE (209)468-3420 MAY 61992- <br /> P <br /> 1992-P 0 BOX 2009, STOCKTON, CA 95201 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT =IRES 1 YEAR FROM DATE ISSUED PERMIT/KP /ICES <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 <br /> /�{YY $ Lot Size/Acreage <br /> L/L/t/t_ � <br /> r Phon <br /> Owner's Nam <br /> i cense No. Phan <br /> o tr o e <br /> W <br /> P: EW WELL ELL REPLACEMENT DESTRUCTION ❑ Out of Service well ❑ <br /> TYPE OF WELL/PUMN <br /> PUMP INSTALLATION ] SYSTEM REPAIR ❑ OTHER C <br /> Monitoring Well L1 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _ SEWER LINES DISPOSAL,FLD` PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER_LIVELL PITS/SUMPS <br /> ,INTENDED U.SE__._r-_T_Y.PE_QF WELL PROBLEM AREA CONSTRUCTION SPEClFICATtONS' <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E'xcauation. of_Vti+ ll`Casine <br /> l Type of Casi,,,,�./i "' Specifications. <br /> C] <br /> Domestic/Private 0 Gravel Pack L7 Tracy o � �, . <br /> I.1 Public la Other n Delta Depth of-Grout-seal "�' _ Type of Grout <br /> kwrrI{Iation Approx. Depth I I astern urfac Seu�Installed by /A <br /> H p ! SEate Work Don �L•� <br /> Repair Work Done U Type of Pump /f Sealing'Material &`,DepthWell Destruction ❑ Well Diameterth <br /> Depth Z / Fill Hit,Hit riel,& Dep <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAWAID ITION { I DESTRUCTION I I INo septic <br /> sy ism rMit ed if public sewer is {� <br /> / �} 01 <br /> Installation will serve: Residence Commercial Oiher s <br /> Number of living units: Number of bedrooms 1' <br /> Character of soil to a depth of 3 feet: Water table,depth. <br /> ,y _ ,.,............. �. r <br /> SEPTIC TANK ❑ Type/Mfg Capacity "*"° No. Compartments ,y <br /> �4__ "`Methl—of Disposal <br /> l PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property,Line <br /> Total length/size <br /> LEACHING LINE [I No. & Length of lines ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property One <br /> r <br /> a Number <br /> i SEEPAGE PITS l 1 Depth Size <br /> SUMPS 0 Distance to nearest: Well Foundation j 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 fegulations 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 signature \� <br /> certifies the following: "I certity that in the performance of the work for which this pirmit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> t The applica ust call fa I equire inspections. Complete drawing on rev909 side. <br /> Sign <br /> Title: Date: <br /> - d ,,,_._-.,,,..,r _ _..�-.—•--._.._._..,_, - <br /> FOR DEPARTMENT USE E ONLY <br /> APP f3 <br /> Application Accepted by Date Area _ V -- 4 — <br /> I ^�^ <br /> Pit or Grout Inspection by <br /> Date Final Inspection by �JYv Data <br /> i Additional Comments: <br /> Applicant - Return all copies to: San Joaquin.County Public Health Services <br /> l Environmental Health Permit/Services <br /> l 445 N San Joaquin,, P 0 Box 2009, Stkn', CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED � 'CK RECEIVED BY DATE l ERMIT NO. <br /> 1N <br /> CASH <br /> 11A« EH 13.21 IRFY. /a S! �/I -6 <br /> EH 11-2a <br /> 4 <br />