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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> AV <br /> S P 0 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 /> Job Address® r ".b",".� City�� Lot Size/Acreage <br /> wn is Name 7 jflf�ddress Phone <br /> Con�fa2tor ddress � � � � License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .. DESTRUCTION Out of Service Well 10 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring }dell <br /> DISTANCE TO NEAREST: SEPTIC TANK 90�_SEWER LINES DISPOSAL FLO. f PROP. LINE <br /> FOUNDATION 7 AGRICULTURE WELL ""OTHER WELL /_Z!_1__PITS/SUMPS l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J 1 �s <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 17,11r •.Dia. of Well Casing` <br /> 'Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ ' Specifications lAto� <br /> {'1 Public Cl Othee n Delta Depth of Grout Seal � d16 Type of Grout — <br /> 1 1 Irrigation App x. Depth I I Eastern Surface Seal Installed by I <br /> Repair Work Done U Type of Pump � H:P. � - State Work Done Y f <br /> _- �r..�Sealing_Matexial�&�DSptki� l L __._ �"� <br /> Well Destruction ❑ Well Diameter <br /> � - - �— "�- <br /> Deptftc 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 v\' <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial? Other <br /> Number of living units: Number of bedrooms ( I <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 (� a <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 1 <br /> SEEPAGE PITS 11 Depth Sire _ Number ' _ <br /> SUMPS LI Distance to nearest: Well -- "Foundation Proppeerty Line, ` <br /> DISPOSAL PONDS ❑ 'd <br /> 1 hereby certify that I have prepared this application and,that the work will be done`iri accordance witli.San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County kf ,y 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify thavin <br /> 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 compensati6n-laws of California 'G6ntractor's'hiring or sub-contracting signature 1 <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• 1 <br /> tion laws of California" <br /> The applican r II req ire t tons. Complete drawing on rev rs_e side. a <br /> Signed Date:- t <br /> iVFfS `ONLV r � '-Y <br /> Application Accepted by t Date Area oil <br /> k <br /> Pit o Grout nspection by Dat ,Final Inspection by Data <br /> p` s <br /> Additions) Comments: <br /> 0ti` ` <br />-- Applicant-- -Return•,►►-copies-to:-=%San=Joaqu in-County-Pu'blic Hea1'th"-Services <br /> _ . _,. <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT fED Ler CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> NF ` (�l57�)I <br /> ♦ EH 3-24 EH 1t 2a(REV. x 5) ,Q-� V Jo 7�3-9�_ o <br /> �3 <br />