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S: <br /> SAN JOAQUIN COUNTY P'DBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> {� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ctvr+. e �� (Complete in 'Triplicate) <br /> Application is hereby made to q Y <br /> San Joaquin Count for a permit to construct and/or install the vork 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 /> CitySize/Acreage <br /> Job Address <br /> 4e <br /> t Phone <br /> Owner's NameAAddress r��� <br /> Contractor <br /> '� Address ( � License No �C/ 0 -Phone �� <br /> TYPE OF WELL/PUMP. 1 r 1, I� NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION LJ Out of Service well 0 <br /> / SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION O <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 /> M Industrial O 0 "n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XfDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i Public 1:1 Otrier f1 Delta Depth of Grout Seal Type of Grout <br /> ti _Approx. Depth I I Eastern Su SeuI installed by <br /> i I Irtioa on <br /> �+r� <br /> Repair Work Done 6d ,Type of Pump .—s H <br /> .P. .1State Work Done <br /> Well Destruction, D 'Well Dibmetbir f. . " sealing'Material & Depth <br /> neptF rFiller Idaterial`& Depth Q� <br /> TYPE OF SEPTIC WORK ;-NE EW INSTALLATION I I -REPAIR/ADDITION I I DESTRUCTION I l IN,, septic system permitted if public saws, is <br /> Illi 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 /> Capacity No. Compartments <br /> SEPTIC TANK. O Type/Mfg � Y <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: 'Well Foundation Property Line <br /> R il. <br /> LEACHING LINE ❑ No. & Length of fines ` Total length/size <br /> FILTER BED n Di§lance to nearest: Well Foundation Property Line <br /> SEEPAGE PITSI I Depth Size Number ' <br /> SUMPS Ll Distance to nearesp" Well Foundation — Property Line <br /> DISPOSAL PONDS ❑ �I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquih,bounty ordinances, state laws, and <br /> rules and regulations of the San Joaquin County. `3 <br /> Home owner or licensed agent's si natufe certifies the following:^"f certify that in the performance of the work for which this permit is issued, I shall not <br /> Ho e g 9 <br /> employ any person in such rs►anri'er as to become subject to workmen'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 workman's compensa- <br /> tion laws of California." <br /> F The appsmust I for all required i coons. Complete drawing on rev side. <br /> I <br /> Signed X Title: Date: <br /> II FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �Aa <br /> i, Pit or Grout Inspection by I� Data Final Inspection Date -� <br /> Additional Comments: I� <br /> F Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Hox 2009, Stkn, CA 95201 <br /> FFTE—F AMOUNT DUE AMOUNT REMITTED "A RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> �Zs Lem r4f t <br /> f . EM 13-241REV.rih31 �I`0o <br /> EH 14.20 <br /> k � <br />