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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 71—P 't.� SSI: .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 <br /> 3PLO' &aeQ� -.� ��+— City G Lot Size/Acreage <br /> Owner's NameLta-t, Address tom. Phone <br /> f/JI <br /> Contractor L Addresatv Ucense gy�Phone <br /> 'TYPE OF WELL/PUMPt NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION LI-Out of Service Well 0 <br /> PUMP INSTALLATION5a SYSTEM REPAIR)C <br /> OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROPttINE <br />` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU ps <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial } D Open Bottom D Manteca Dia. of Well Excavation Dia. of Weil Casing" v <br /> 1 <br /> Domestic/Private 0 Grove' Pack ❑ Tracy Type of Casing_ �' Specifications <br /> I'I Pub[ic �r ill Other r l7 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx, D `tth I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump ! H.P. State Work Done 0. <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diaeter <br /> '� m <br /> f Filler Material ii Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: ]_REPAIR NEW INSTALLATION I /ADDITION I I DESTRUCTION I i 1No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will terve: Residence— Commercial___ Other <br /> Number of living units:V Number of bedrooms `a <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 <br /> Distance to nearest: Well Foundation Property Line <br /> i - <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Y' Property Line <br /> SEEPAGE PITS 11 Depth Size r ` Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS 0 <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.CaRofnia."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work fol which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion lei 11 <br /> 0 la." f <br /> Th applicant m t call for all requ' inspeeti Complete drawing o else side. <br /> Signed u Title: Date: /B <br /> 7�� R DEPARTMENT USE ONLY <br /> ' turd Date _I � Area_ 6. ZW <br /> Application Accepted by � - � <br /> Pit or Grout Inspection by Date Final Inspection by Dated 3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Per t/Services <br /> 445 N San Joaquin, x 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> e INFO l <br /> . EH 13.24 IREV. n 3�Y� r <br /> EH 14.26 111 <br /> l - <br />