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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AN �( Irt�t r /� <br /> ,r� ,� ENVIRONMENTAL HEALTH DIVISION <br /> /! ,�/ 445 N SAN JOAQUIN, PHONE (209)468-3420 PO/ /0/ <br /> V P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t,Je (Complete in Triplicate) <br /> dk s. <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 236 C ALM1)AJ f�) D(L City Lot Size/Acreage <br /> owner's Name (OL VIAS f%h1N� pTP Address I Zvi 0. TO iLwe S7"• Phone <br /> Contractor DON �- 1 Tn�[. Address 9 700 97• m, a. PmSH- R_d License No. t�vZl Sas Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 Public (:1 Other n Delta Depth of Grout Seal Type of Grout ' J] <br /> I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by v <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 I REPAIR/ADDITION ( I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence e 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 D Type/Mfg CCKX-(44^1_6 Capacity No. Compartments _-- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal Q <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 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: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 applican st cal f r all tred ins ction . Complete drawing on reverse side. <br /> Signed X Title: dZil - Date: �3 g <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1�,�.� Date Area 10 Z �/ <br /> Pit or Grout Inspection by (Date Final Inspection by Date <br /> Additional Comments: 10-"` ,.., to LL <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT'NO. <br /> EM 3-24 EH11.2eIREV.iix51kp t7 / u-, �- I / IVA3 I <br />