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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> Al P 0 BOX 2009, .STOCBTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade 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 Y_ � City Lot Size/Acreage <br /> r� P A � ' <br /> Name - <br /> wn is `� � C�J ddress Phone <br /> Gon�tr'attor ddress � � ® e-� License No. Phone �^ <br /> TYPE OF WELL/PUMP: NEW WELL LJ WELL RE .PLACEMENT DESTRUCTION Out of Ser"vice Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER G Monitoring Ylell <br /> DISTANCE TO NEAREST: SEPTIC TANK _�SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION � AGRICULTURE WELL ®OTHER WELL �Z_SPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONzS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation �?%• Dia. of Well Casing, <br /> -Domestic/Private )(Gravel Pack f ❑ Tracy Type of Casing_ �— SS cifications <br /> i"I Public 1:1 Oche / n Delta Depth of Grout Seal i`Qf?rYPe of Grout <br /> I I Irrigation A"pp�6x.Depth I I Eastern Surface Seal Installed b, <br /> Repair Work Done U Type of Pump H.P.- 7S Stato Work Done I <br /> Well Destruction ❑ Well Diameter � Sealing_Material &:,Peptl'% <br /> Dept h% Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is V\ <br /> available within 200 feet.) (��ll <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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line i <br /> k <br /> LEACHING LINE ❑ No. & Length of lines + a Total length/size ` <br /> V , <br /> FILTER BED ❑ Distance to nearest: Well Foundation - - Property Line <br /> # u r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well --Foundation Pro rtV,,Lino,_ i <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 l <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 Calif ornia.=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 applican I 11 req re. 1 ions. Complete drawing on rev rae side. I <br /> Signed X .itle� ` r Date:- <br /> t tlFEN�HtiS ONIY �` <br /> j� t-- �1 <br /> Application Accepted by t Date Area <br /> f <br /> Pito Grout Inspection by Date ., - AFinal Inspection by Date <br /> AdditionalComments: <br /> / ' � F. +r/t - <br /> C,�.�_ _ to ♦ ...... '.....v. �` ��...y-. <br /> Applicant --Return•-al l•-copies-tot-�-=San�-Joaquin�County;Pu-U is Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K 1 `RECEIVED BY DATE PERMIT•N0. -7 <br /> INFO / <br /> / / (g3709 <br /> . EH 13-24(REV.1i 95# Do 1 7- [/�� <br /> EH 11.26 '�� 71c�� /� / a1 - <br />