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SAN JOAQUIN COUNTY PUBLIC HEALTH. SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> - 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> J� 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 t) n L � City Lot Size/Acreage _ <br /> s 'Address Phone <br /> Owner's Name ^ . <br /> License No,?+��f h <br /> � one <br /> Contractor Address <br /> TYPE OF WELL/PUMf?: NEW WELL ❑ WELL REPLACEMENT t'l DESTRUCTION ❑ Out of Service Well ❑ <br /> ` I PUMP INSTALLATION O SYSTEM REPAIR.-'D OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> �.. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [J Domestic/Private . ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> y I'] Public - -' + Cl Other 11 Delta Depth of Grout Seal Type of Grout <br /> t <br /> 11 Irrigation f —,Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work'Done 0 Type of Pump H.P. State Work Done — <br /> o <br /> Well Destruction ClWell Diameter Sealing Material & Depth <br /> Depth <br /> Filler Material b Depth h I <br /> I" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i' REPAIR/ADDITION DESTRUCTION I' i_ (No,septic system permitted if public,sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residijiica' ommerciif. Other <br /> Number of living units: 4— Number of bidrooms_ „� ' _ ,, <br /> Character of soil to a depth of 3.feet: . ,' • �J Water table depth I. <br /> I SEPTIC TANK ❑ j Typ6YMfg Capacity 11•o No. Compartments <br /> i <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> ,Distance tojnearest: Well Lam= Foundation S F�P�roperty.`Line 'n <br /> LEACHING LINE �,(fTlo. & Length of tines '- ® Total length/size �r <br /> Q`1 \"�� <br /> FILTER BED n t Distance to nearest: Well. �r` Foundation .60 Property Line -- �p� <br /> r SEEPAGE PITS [ I Depth Sire er ` <br /> i <br /> SUMPS Distance to nearest: Well Zj 14 FT Foundation Property Line <br /> DISPOSAL PONDS ❑ W 1 <br /> I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, hate laws, and <br /> ,.rules and regulations of the San Joaquin county <br /> Home owner or iicensed agent's signature certifies ttie following; "I certify that ffi the performance gf'the work.fot.which this permit is issued, I shall not <br /> employ any persorti in such manner as to become,aubjact to.workmen's_dompin'sation-iaws.of.California."Contractors hiring-or-sub-contracting-signature- <br /> cinifies Wifollowing: 'I certrfy that in the performance of the work for which this permit is issued, I shall employ persons subject_to workman's c�ompensa- <br /> :r-� �ytidri 1ew�iif"Califari5fa:' ---w- � .�. .. -...-, _,� - ,..� .�._.y.=,,,,..�.. -..,..,.... ,....•��.. <br /> The,applicant must call for al requi!!0 inspections. Complete drawing on reverse side, <br /> Signed Title: _ Date: <br /> i <br /> 011 D ARTME USE ONLY <br /> Application Accepted by Data �'� Are <br /> i <br /> Pit or Grout Inspection b e Date Final Inspection by 4444< <br /> Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Perm .,- <br /> it/Services , _' w•-- - - <br /> "445 N'"San 3oaquxn, Box 2009, Stkn, GA.95201 <br /> FEE AMOU DUE AMOUNT REMITTED -btz� <br /> ECEIVED BY TE PERMIT'NO. <br /> EH 14.2.EH 13.24IREV.r/X5V i O /� �/ r 7 <br /> W__(//Y/C/ <br /> r <br /> t� <br />