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X, <br /> 1. 1ALSC SAN JOAQUIN"COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ti ! 445 N SAN. JOAQUIN, PHONE `(209)46$-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. 549 and 1862 and the Rules and Regulations of San <br /> r Joaquin County Public Health Services. <br /> I r <br /> Job Address ., / City Lot Size/Acreage { <br /> Owner's Name Address <br /> Contracto QL A'IAddress No. Ph e <br /> TYPE OF WELL/PUMP: NE WELL _ W LL REPLACEMENT .. DESTRUCTION Ll'Out of Service Nell LiL <br /> I r PUMP INSTALLATION � SYSTEM REAIR OTHV 0 Monitoring Well <br /> �7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ' "SEWER LINES / DiSP_OSAL FLD, PROP. LINE '�� <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "' <br /> INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPECIFI.CATIO S <br /> fn �Indd 1 pen Bottom ❑ Manteca Dia. of Well Excavati r Dia. of Well Casing <br /> [�YAomesac/Private 0 Gravel. ❑ Tracy Type of Casing_ Specifications ` <br /> I'i Public Cl Other f n Delta Depth of Grout Seal j Type of G t h <br /> I i Irrigation Approx. Dept I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P, - Z State'-Work Done <br /> Well{Destruction ❑ Wel! Diameter �� Sealing Material & Depth i <br /> i Depth Filler Material & Depth ' I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ! INo septic system permitted if public sewer is <br /> i available within 200 feet.) ; <br /> Installation will serve: Residence Commercial_ Other p <br /> I I � <br /> Number,of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r a. <br /> SEPTIC TANK ❑ Type).Mf Capacity, r No. Compartments <br /> PKG l TREATMENT PLT.0 �,7► � -, � � ' Method of Disposal j <br /> - i = <br /> Distance to nearest: Well Foundation '���rbperty Line � ''• <br /> LEACHING LINE 0 No. 8 Length of lines r Y Total length/size <br /> .s <br /> w FILTER':BED ❑ Distance to nearest: Well Foundation � Property Liner. <br /> SEEPAGE PITS I'I Depth Size Number <br /> SUMPS' [l Distance to nearest: -Well <. Foundation f Property-Line i <br /> DISPO AL PONDS' ❑ <br /> •' I hereby certify-that I have prepared this application and that the work will be done in accordance with Sari Joaquin couniy ordinances, state laws, and <br /> rules�an¢ 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 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 Vvorkman's compensa- <br /> tion laws of California." tE` , <br /> The applicant m ca for all r uired ctio Complete drawing on re2,0111, <br /> side. s r. <br /> Signed Title, ' rJ Date:�- <br /> r — DEPARTMEN <br /> Application Accepted by Date ����, � Area 1µ <br /> Pit or rou Inspection byT w ate 2Fi I Inspe tion by Date. ` C <br /> Additional Comments: ' 0 <br /> Applicant - Return all copies to: San Joaquin County Public Health Sery s <br /> Env <br /> �, � � �� 4451NoSannJoaquintal �tP O Boxt2009vices <br /> Stkn, CA 95201 <br /> CK 11 <br /> IFEENIF AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'N0. <br /> q2 , <br /> rEH13-241REV.�/h51w cr �171 <br /> � <br /> EH 14.20 1 <br />