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V" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> \ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 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 Services. <br /> / 1 <br /> Job Addr /�/r l p City G Lot Size/Acreage <br /> ess (p i d <br /> Pa dJ Q(r( S Address !6 31 <br /> A/"f. A l p t Phone —q3j— <br /> Owner's Name n / Art Q <br /> Contractor A r �� P Address <br /> fj P /c r� 6(�Nt QLicense No. -b 7► Phone v� —� <br /> WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL <br /> PUMP INSTALLATION t& SYSTEM REPAIR O <br /> OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK IAb I� SEWER LINES 00 11-'- DISPOSAL FLD. PROP. LINE _12.1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —_-- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation. Specifications r <br /> Domestic/Private QWravel Pack O Tracy Type of Casing_ <br /> I'1 Public 1.1 �Qther n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump — H.P. 1112 State Work Done <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (Nailsepticable tisystem rented if public sewer is <br /> Installation will serve: Residence_ .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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <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 Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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' nrq or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall employ erl4ct to workman's compensa- <br /> tion laws of Califor <br /> The apptican st call for all-7e d ins igns. Complete d wing on reverse side. q -/ <br /> 7-13 <br /> P —� Title: — 4D#ate ' <br /> Signed X <br /> R DEPARTMEN USE ONLY <br /> a <br /> Date "_ <br /> Application Accepted by <br /> Pit o rout nspection by <br /> ate qA - Final Inspection by Date <br /> Additional Comments: J ��� _ 6>� I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services , <br /> Environmental Health Permit/Services <br /> 1 <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO * <br /> W <br /> �6y�7 <br /> . EH 13.24IREV.I/ 13 4 o <br /> EH 14.26 <br /> 2 .7 <br />