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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 /> 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 �S y v City 9 Lot Size/Acreage <br /> Owner's Name"LLIO&Z Address Phone <br /> Contractor EDOAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C1 OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) Industrial. O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XpomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 4 <br /> I'1 Public El Other n Delta Depth of Grout Seal Type of Grout �J <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump H.P. State Work Done _ <br /> Well Oestruction 0 Well Diameter Sealing !Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms 'w <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal 9 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 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 64nances, state laJandrules 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 sano <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 rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all a tnspactions. Complete drawing on�reverse <br /> �side. <br /> Signed Title: ,/r .f�i� �� Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date rea d <br /> Pit or Grout Inspection by Date Final Inipection b Date <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, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED gCA(;SCK 0 RECEIVED BY j f DATE PERMIT'NO. <br /> . EK 13.24 tREV.rinse�� f�t �� 1 l A, 7" 2 •+O <br /> EK 1426 Y J <br />