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SAN JOAQUIN COUNTY PUBLC HEALTH SERVICES <br /> Q ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> f ct� 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City_ <br /> Lot Size/Acreage <br /> Job Address c <br /> jt/, - P'G�. O.ASr�J Address ^-a� � Phone <br /> Owner's Name e-.----- <br /> Contractor <br /> Address �`� f �s�M License No � Phone�� <br /> TYPE OF WELL/PUMP: NEW WELL C3of service Well 0 <br /> WELL REPLACEMENT ❑ DESTRUCTION O Out Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR tC, OTHER O <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 /> Dia. of Well Excavation -- <br /> Dia. of Well Casing <br /> n Industrial O Open Bottom ❑ Manteca <br /> Type of Casing- Specifications <br /> 0 Domestic/Private O Gravel Pack El Tracy 9- <br /> I"1 Public (-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. De 1 Eastern Surface Seal Installed by D <br /> H P. State Work Done_ Q(�t/ <br /> Repair Work Done 0 Type of Pump Sealing Material & Depth <br /> Well Destruction O Well Diameter <br /> Depth Filler Material & Depth ^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 ❑ -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 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 appli must all for all required i ctions. Complete drawing on rev s side. <br /> Signed X Title: �,� Date: <br /> OR DEPARTMENT USE ONLY C� f <br /> Application Accepted by r� ���+�n(11ti.r�[1 Data �2-!T Area 2� I' <br /> Ad JIMAA4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RE VED BY DAT PERMIT'N0. <br /> INFO r <br /> . EM 13-24(REV.►/N 5) 0/0 is� <br /> � / — <br /> EH 14.2E <br />