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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION "' '~'" <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 ; <br /> P O BOX 2009, STOCgTON, CA 9520Y <br /> r _ J U L -D 21902 <br /> PERMIT EXPIRES Y YEAR FROM DATE ISSUEENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations_ of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> I City Lot Size/Acreage . <br /> 1 er's Name AddressPhan <br /> - <br /> Und,rac r ' <br /> reCal <br /> kULi <br /> TYPE OF WELL/PUMP: NEW WELLhone ✓��J l�� <br /> WELL REPLACEMENT F] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring`Well <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 /> I n =I d ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "" Dia. of-Well Casing'?"` <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> ('I Public Specifications f <br /> fa Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> I i Irrigation _.Approx, Depth l I astern Surface Sea! lnstaBed by ' <br /> Repair Work Done U Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Weti Di meter Sealing Material & Depth <br /> Depth Filler Material is 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 <br /> Installation will serve: Residence— Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> ❑ Typa/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity_ No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. $ Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well _Foundation. <br /> Property Line .- <br /> i <br /> SEEPAGE PITS 11 Depth Sire Number ' <br /> SUMPS L) Distance to nearest: Well Foundation <br /> Lie <br /> DISPOSAL PONDS ❑ ,} Property Line <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 6rdinances, 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 permiit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws oj-Californii."Contractor's hiring or sob-contracting signature <br /> certifies the following: "I certifythat in the performance of the work for which this permit is issued, I shall employ p p y persons subject to workman's compensa- <br /> tion laws of California." _ <br /> The applican u t ca! 'red i spestions. Complete drawing on rever side, M <br /> Si ed' Title: 9 <br /> Data- <br /> OR D <br /> ate-ORD RTMENT USE ONLY <br /> Application Accepted by <br /> Date Area p� <br /> Pit or Grout Inspection by Date <br /> Additional Comments: Final Inspection by l <br /> .-Date <br /> Applicant — Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services 99 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED 1 <br /> FO <br /> CK RECEIVED BY DATE PERMIT'NO. <br />• EH 13.24 IREV. /w 51 <br /> EH 14.26 I' V <br />