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- r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)458-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mabe.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. 51+9 and 1.862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 0 10 M K 4 - - — City Lot Size/Acreage <br /> Owner's Name _ f �l t q:�\. w- Addressr � ��`-U`V,JPhone <br /> / i� _ r q5 L c!,► <br /> Contractor <br /> 4 Address 6-2 S t T � %i _�� License No. � �– Phone 1 <br /> TYPE OF WELL/PUMF75 NEW WELL E WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION L7 SYSTEM REPAIR �OTHER G Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK i CSS _ SEWER LINES ./ DISPOSAL FLD. __ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL / OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> f� Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �l !,L;(Ifs A Dia. of Well Casing iti,l <br /> I I Domestic/Private D Gravel Pack' ❑ Tracy Type of Casin S <br /> g .._���� �5pecifications ' € <br /> I'1 Public Ll Other i-1 Delta Depth of Grout Seal ` C-!1./as' Typ fu�r�Sut_ lit Ir f <br /> frripation __.Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ Nn <br /> Well Destruction ❑ Weil Diameter Sealing Material & Depth Q <br /> IQ VIi Depth Filler Material it Depth <br /> TYPE OF SEPTIC K: NEW INSTALLATION I i REPAIRIADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is <br /> available-within 200 feet.) ? <br /> Installation will serve: Residence _ Commercial _ Other 4+ <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: , Water table depth <br /> SEPTIC TANK C3 Type/Mfg opacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i" Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ! <br /> LEACHING LINE L7 No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: i Well Foundation Property Line <br /> SEEPAGE PITS Ii Depth Size Number <br /> SUMPS LI Distance to rest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> l hereby certify that I have prepared thisapplicationand that the work wilt 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 follo ing: "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 Iowa of Calif rni .' <br /> The applicant s eq ed ins Complete drawing on reverse side.A. <br /> J <br /> Signed X Title: L r '//lam Date: <br /> FOR DEPAR7, ENT US ONLY,, <br /> Application Accepted by �� Date Z` 3 b -q 2� Area <br /> Pit or dtiQlt Inspection by Date Z (/ Fin I Inspection by -P Z2 11—` Data 4/` <br /> Additional Comments: <br /> O N ' <br /> ,?Applicant - Return all copies..to: San Joaquin County Public Health Services `"�} �,%� 4.. 2-63 <br /> o <br /> Environmental Health Permit/Services v / <br /> 7` EDW PiC� 945 N n JQa n, P O Box 2009, Stkn, CA 95201 <br /> 2,7 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY / DAT PERMIT"NO. <br /> CHH 14..26 IRE ixsl v\! �3-1 <lZ? L7 l =0f3 <br />