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ll .l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �} P 0 BOX 2009, STOCKTON, CA 95201 <br /> f/ PERMIT EXPIRES I 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 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. e�+ A� �j�o� <br /> Job Address _� �"rf rr' 4 224)60`9 . 16/� �0tt' F= Lot Size/Acreage <br /> Owner's Name Address Phone / <br /> or <br /> Contractor Address �� License No, Phon [ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION E3 ,, SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <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 /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack L) Tracy Type of Casing_ Specifications <br /> I'I Pyblic C7 Other n Delta Depth of Grout Seal Type of Grout <br /> `vr .9ation —.Approx. Depth I Eastern Su ee Seal installed by <br /> Repair Work Done V Type of Pump H,P. Stat® Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & 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 Q <br /> available within 200 feet.) <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 ❑ Type/Mfg Capacity No. Srfm PKG. TREATMENT PLT. ❑ Metro <br /> Distance to nearest: Well Foundation Property Li - <br /> ;srs 1922 - --- <br /> LEACHING LINE ❑ No. & Length of tines Total length/size �� rnt;rtITY <br /> FILTER BED C7 Distance to nearest: Well Foundation Pro AN iut I Ir+,Tl� F R�14C�S <br /> F kL11": 117;�J i;J <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 taws, 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 pare i uch manner as to beco subject to workman's co"ves <br /> f California." Contractor's hiring or sub-contracting signature <br /> certifies the foil i . "Ice that in the ormance of the work for wsued, I shall employ persons subject io workman's compensa- <br /> tion laws of ii o la." <br /> The appli m call f c cons. omptete drawing o <br /> Signed X Title: Date: �rr� <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by Date <br /> Area Zl� <br /> Pit or Grout Inspection by Date Final Inspection by Date /T2 <br /> Additional Comments: _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMITNO. <br /> INFO <br /> . EN 13-24 IREv.1/851 � qrg- <br /> Q ZZ 92,2 <br /> I, EK 11.2e J <br /> l - <br />