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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> " 5 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 City ) Lot Size/Acreage <br /> Owner's Name l[�S ��Address g"A^416 ls_1211t Phone 6 <br /> '99 <br /> Contractor Address1= License Nos- Phone l <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT CSI DESTRUCTION Cl Out of Service well ❑ <br /> PUMP INSTALLATION W' C7 <br /> SYSTEM REPAIRwr OTHER C3 Monitoring Well U <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 /> f} Industrial O Open Bottom 11 Manteca <br /> Dia.of Well Exca`vatiori,""- "" Dia.-of-Well-Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public (-I Other Cl Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —.Approx. Depth <br /> s� tt I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. I' _ =— Stats Work Done <br /> Destruction O Well Sealing Material & Depth <br /> Wetl Diameter <br /> `` t0epth. - Piller Material & Depth 1t.1 L(�tll T <br /> TYPE OF SEPTIC WORT(; -NEW-INST-AL-LATiON 1-1-REPAIR/ADDITION-(-I-DESTRUCTION.1-IYINo septic-system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial — Other. <br /> i Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: x ` <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No.'Compartments <br /> PKG. TREATMENT PLT.❑ 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property tine <br /> t - <br /> F LEACHING LINE ❑ No. & Length of lines Total length/size'-­ <br /> FILTER <br /> ength/size"- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> 4 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O 1 t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> rules and regulations of the San Joaquin County; i - <br /> j Home owner or licensed.agent's signature certifies flie following:--';I certify that.in.ihe performance of the work for which this-permit is issued, i shall not <br /> empioy 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 /> t tion laws of California." <br /> The applicant must call for all required inspect ns. Complete drawing o everse side. <br /> a <br /> Signed X Title: Date: <br /> r FO DEPARTMENT USE ONLY C. <br /> Application Accepted by Date �` yZ" Area <br /> Pit or Grout Inspection byDate Final Inspection by Dates <br /> Additional Comments: <br /> Ir Applicant Return all copies to: San Joaquin County Public Health Services <br /> r Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE `AMOUNT DUE AMOUNT REMITTED GASH RECEIVED HY pATE PERMIT'NO. <br /> INFO ,wry <br /> . EH 1724(REV.7/R S! <br /> EH 14.26 x - - <br />