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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 S <br /> P O SOX 2009, STOCKTON, CA 95201 <br /> 0 <br /> APERMIT 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 /> ' F <br /> "OE <br /> 60FL� <br /> Job Address c44Cit Lot Size/Acreage <br /> J / <br /> Address 4W <br /> Phone ~v <br /> Owner's Na --- <br /> t / <br /> C t7 " <br /> Contractor d re LUe PCeI4 No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN C_l� <br /> ?� DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION O SYST..fM REPAIR4�, OTHER ❑ Monitoring Well l7 <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-1 II dustrial ❑ Open Bottom ©_Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �,YDomestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications t ' <br /> i"1 Public 1-1 Other 171Delta" Depth of Grout Seal Type of Grout <br /> I i Irrigation ,____ Approx. tDe �41 " <br /> ternSurface Seal Installed byRepair Work Done 0 Type of Pump� H. State Work D _ <br /> We -.....••r Sealing Material & Depth Weil CJ Well-Diameter _ <br /> Depth F ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is <br /> available within 200 test.) <br /> stallation will serve: Residence_ Commercial_ Other ` { <br /> Number of living units: Number of bedrooms ✓ <br /> Character of soil to a depth-of,3 feet: t "' t 9 y Water table depth K. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ) <br /> PKG. TREATMENT PLT...-;t * Method of Disposal <br /> Distance to nearest: Well .Foundation Property Line <br /> LEACHING LINE kn No.'& Lengtfirol lines f Total length/size t <br /> FILTER BED iG]a Distance-to nearest: Wall Foundation Property Line \� <br /> SEEPAGE PITS I I Depth Size Number i <br /> SUMPS t Cl ;Distance to nearest: Well Foundation Property Line <br /> DISPOSAL,PONDS). J0 _N <br /> f hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, 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 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 workma;co' pensa- <br /> tion laws of California."The applica u c I req ed i s. Complete drawing on reverse s'Signed X ills: Date: <br /> Ic R DEPARTMENT USE ONLY q j <br /> Application Accepted by _91�.. Date M 1 Z Area 2 <br /> Pit or Grout Inspection by Date Final Inspection by !Date <br /> t <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, GA 95201 i <br /> FEE AMOUNT DUE AM NT REMITTED K RECEIVED BY DALE PERMIT'N0. <br /> INFO <br /> i F EEH H 13-24(REV.1)K5) {� Z Jf, L <br /> I V �J Ci I <br />