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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E C E I V E D <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Q 445 N SAN JOAQUIN, PHONE (209)468-3420 J U N 19 1992 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL- HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> City_ --- Lot Size/Acreage <br /> Job Address ` t r r !=�'- r'a'-� 2 p <br /> t�� V1 T1 Phone �J �(S <br /> Owner's Name ty �IC�Address IK (< Cly <br /> Contractor <br /> Address License No. `tP Phone <br /> WELL REPLACEMENT . DESTRUCTION ❑ Out of Service Well <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - OTHER ❑ Monitoring Well C1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> `DISPOSAL FLD. PROP. LINE <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 ❑ Manteca Dia. of Well Excavation <br /> Type of Casing_. Specifications <br /> Cl <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> Public (1 Other n Delta Depth of Grout Seal <br /> Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> `+'.A H P J� State Work Done <br /> Repair Work Done U Type of Pump _ Sealing material & Depth <br /> Well Destruction ❑ Well Diameter __IQ—, Filler Material i Depth <br /> Depth / D <br /> TYPE OF—SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION 1 I availableNo so rwithin 20c system 0 feet.)rmitted rl public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> C <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments Method of Disposal <br /> � <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl 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 /> 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: "t-certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol lowi g "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 <br /> The applica call for all req i d inspec 1 ns. Complete drawing on eve side. <br /> Title: Date: <br /> Signed X <br /> R PARTM USE ONLY <br /> Application Accepted by <br /> Date �Area <br /> Pit or Grout Inspection by <br /> 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 /> FEE CK ECEIVED BY ATE PERMIT N0. <br /> INFO <br /> /EE AMOUNT DUE AMOUNT REMITTED CASH <br /> . EH 13.24(REV.1 i n s) J <br /> EH 14.26 I <br />