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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES Y 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> City c'! I,ot Size creage _ <br /> J <br /> Owner's NameAddress <br /> l!'-,.� 1�'-��� € ..�•'.,r'i< f �- � <br /> /- ,�, t <br /> {. Phone <br /> Contractor r�yCAddress _ <br /> License Ne phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7, OES?RUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �.; Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER `_' �7 <br /> SEWER LINES DISPOSAL F-D.__�_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava:ivn <br /> I Domestic/Private Ll Gravel Pack ---- Dia. of Well Casing <br /> [7 Tracy Type of 9 Casin _ <br /> ...------��_..-_-- Specifications <br /> I"1 Public C1 Other [7 Delta Depth of Grout Seal _ ^ <br /> Type of Grout_ _ <br /> Irrigation —_ Approx. Depth I I Eastern Surface Saul Installed b�' <br /> Repair Work Done Li T '_re W — =pj�tblicsewer <br /> ype of Pump H.P. StatsWork GoneWell Destruction ❑ Well Diameter Sealing Material & DepthDepth Filler Material & DepthTYPE OF SEPTIC WORK: NSTALLATIDNREPAIR/ApDI71gN i 1 DESTRt1CTION ! 1 +No se sic stemP V permitted i€available within 200 Peet.) 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: y i <br /> SEPTIC TANK — - _.__ Water table depth__ <br /> Type/Mfg �Z�t.' �-0 � CapacitY� No. Compartments Z <br /> PKG. TREATMENT PLT. Cl <br /> Method of Disposal <br /> Distance to nearest: Well Foundation �Idrf <br /> Property Lina <br /> LEACHING LINE V`No. & Length of lines ,3 <br /> FILTER BEDw Total iengtn/size <br /> C7 Di <br /> stance to nearest: Well Foundation G <br /> Property Line , <br /> SEEPAGE PITS I Depth i Size -- <br /> SUMPS Number <br /> LI Distance to nearest: Well '_IOt124— Foundation <br /> DISPOSAL PONDS ❑ r f s l Property Line _-_ <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'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 shat!employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must,call for all required inspections. Complete drawing on reverse side. <br /> Signed X ? Y y., . <br /> Title: ���:��C> d Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by �/�FOR <br /> Date_ i 1 (9 Z AreaPit or Grout Inspection byDate ' <br /> — Final Inspection by Date l f lit —Z— <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 O Box 2009, Stkh, CA 95201 <br /> FEE AMOUN Ot1E AMOUNT REMITTED CK <br /> INF H RECEIVED BY 'ATE <br /> PEAMIT NO. <br /> . EM 13-24(REV.i/A51 f <br /> EH 14.26 <br />