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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> l� P O 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 AService <br /> Job Address `� Git Lot Size/Acreage <br /> Owner's Name Address, <br /> ` Phone <br /> Contractor 'Address License N, �3 Phone <br /> TYPE Of WELL6/PUMP: NEW E_LL 0 ..«. WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REP IR ❑ OTHER C3 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> l ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU N SPECIFICATIONS' <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of 11 xcavation Dia. of Well Casing — <br /> I') Domestic/Private ❑ Gravel Pack ❑ Tracy Type Cas• g- Specifications - -- - - <br /> ('I Public !..1 Other f-1 Delta De of o'ut Seal Type of Grout <br /> I I Irrigation -,_.._ Approx. Depth 11 Eastern dace al Installed by <br /> I Repair Work Done 0 Type of-Pump.,_. H.P. State Work Done V+ <br /> Healing <br /> Well Destruction O Welt Diameteh <br /> r Material & Dept <br /> MDepth ' _ Filler Material &Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION_ir1_' DESTRUCTION l I (No septic system permitled if public sewer is <br /> r �`." available within 200 feet.) <br /> Installation will serve: Residence—r Commercial.— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK a ❑---Type/Mfg A b a aci No. Compartments 47 <br /> PKG. TREATMENT PLT ❑ ! Method of Disposal (� <br /> y / Distance_to-nearest:,,;,.�Wetl Foundation 1� Property Line <br /> e. <br /> LEACHING LINE ❑ No. 8 Length of linea Xotal length/size <br /> FILTER BED ❑ Distance to nearest: Watt ,( oundation Props Line <br /> i SEEPAGE PITS., 1 ) Depth Size titiMbef I <br /> SUMPS Ll Distance to nee sC WeIIFoundation Property Line <br /> DISPOSAL PONDS ❑ 4 <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'a 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 Cali ornla." s <br /> The applicant st tall for auired ins ti ions. Complete drawing on reverse side. f 1 <br /> a-. <br /> Signed Title: -- Datta: <br /> FO DEPARTMENT USE-ONLY 'te t <br /> Applicatin Accepted by Date ea <br /> Pit or Grout Inspection by Date Final Inspection by Oath <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> [ Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520k, r <br /> FE21110 <br /> AMOUNT DUE AMOUNT REMITTED CASH K 0 RECEIVED'BY DATE's PERMIT'NO. ; <br /> INF <br /> + EEH H ti.M IREV.i x SI ���3 f7-A 1-9 z J52 <br />