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' 1 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 /> 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Cit �- Lot Size/Acreage <br /> Job Address <br /> 6 6 r 6 ? <br /> IL Address Phone <br /> Owner's Name <br /> ALM <br /> a <br /> Conti actor dress �a �+ icense No. Phone <br /> TYPE OF WE NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out moon iitoring Well [:3 <br /> PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER ❑ ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.I PROP. LINE <br /> FOUNDATION �- + AGRICULTUR WEL OTHER WELL ! PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS i <br /> I ❑ 0 n Bottom ° ❑ Manteca c Di of Well Excavation ` Dia. of Well Casing <br /> C1 Industria fix <br /> f ifi ations <br /> 5 c c <br /> 1 fl <br /> Domestic/Private <br /> Cl Gravel Pack"--• D Tracy t T pe of Casing_ pe <br /> f- ..M., <br /> f i'1 Public i 1 Other. : F1 Del pth of Grout Seal " ".Type of Grout <br /> t >d <br /> t 1 Irn{lation _..Approx. Depth It astern urface Sedl Installed by <br /> Repan Work Done 0 Type of Pump H.P. t State Work tone _ <br /> Well Destruction ❑ Well Diameter t. <br /> Sealing terial & Depth'' k '~ ; <br /> Depth <br /> Filler terial & Depth«1 s, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION , REPAIR/ADDITION I I DESTRUCTI N l I (No se ptic'system,permit led if public sewer is <br /> �$vailable within 200 feet.) <br /> Installation will serve: Residence— Commercial ther x4 i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity' !No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 f Method of Disp s <br /> Distance to nearest: Well Foundation d— lProperty Line <br /> r ! <br /> d , <br /> k LEACHING LINE Cl No. & Length of lines - Tot9I 1'ength/size <br /> ` 'l. ' roperty Line <br /> FILTER BED ❑ Distance to nearest: Well ouridation t - <br /> SEEPAGE PITS 11 Depth Sizeumf er <br /> SUMPS LI Distance ton rest: Wel Foundation �' € Property Line <br /> DISPOSAL PONDS El _— A Sr- <br /> 4 I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> f rules and regulations of the San Joaquin County`-w tf <br /> t 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 shalt not <br /> II employ any person in such manner as to beco'06e subject to workman's compensation laws iif California.".Contractorrs'1�irling or sub-contracting signature <br /> a certifies the following: "I certify that in the performance of the work for which this per'niii ii leaned, !shall employ persons subject to workman's compensa <br /> tion laws of California." i'" it .f . ,CJ r..` �' ♦ � <br /> The applicant must c II for all req-0 specie s. Com lets drawing'ort'reverse side. ° r i r( <br /> 41- <br /> 23 <br /> Signed rTitle: _¢Date: <br /> ( R DEPARTMENT USE ONLY qty <br /> f Application Accepted by Date ~ Area <br /> Pit or Grout Inspection by Date Final Inspection In Date S <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services � <br /> Environmental Health Permit/8ervices ��jl�e /Lp]� rh}� <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 950L6 , <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13-24 0tEV.t i n s) 0 11 <br /> EH 14.20 <br /> t E , <br />