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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> � 0 ( 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.f Sans <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regula <br /> Joaquin County Public Health Services. City nrr�Ytard <br /> " .Lot Size/Acreage�,•1 <br /> a E. Hw Manteca y <br /> Job Address 123$8 <br /> 1426-5"-LeroyAve. Ri on Phone <br /> Owner's Name -3554 BOerSIRa Address <br /> Purviance DrilleSllnCAddress p.O.Box 64 Linden License N0.377923 Phony 7-3554 <br /> Contractor DESTRUCTION D Out or Service Well <br /> TYPE OF WELLIPUMP: NEW WELL 99 WELL REPLACEMENT E7 Monitoring Well L� <br /> PUMP kNSTAiLLATION ❑ SYSTEM REPAIR 111 OTHER ❑ <br /> ` SEWER LINES �.--•-- DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK — PITS/SUMPS \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /a f pr�+'�%� <br /> INTENDED USE pia. of Well Casing <br /> �1 Open Bottom ❑ MantecaDia.of Well xcavation <br /> E <br /> C� Industria! i• Specifications <br /> 250— <br /> Type of Casing <br /> pamesticlPrivate ❑ Gravel Paci O Tracy Depth of Grout Seal r Type of Grout <br /> I'I Public I 1 Otf+er5�, � (1 pelta <br /> Irrigation`' � rax.,Depth I I Eastern Surface Seal Installed by ^ <br /> of Pump H.P. <br /> -State Work Dane <br /> . <br /> Well <br /> k Repair Work Done L] Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler tlnterial dr Depth <br /> ' Depth h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION E L DESTfiUC7tON l I available rwthin 20stem 0 feet.) <br /> I! p"blit sower is <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity ` No. CoMpartments. <br /> SEPTIC TANK. ❑ Typo/M1g- Method of Disposal <br /> PKG. TREATMENT PLT. ❑ �; Pro rt Line <br /> Distance to nearest: Well Foundation Pe Y <br /> ❑ No. & Length of lines :Total length/size <br /> LEACHING LINE Y fi ro rt Line <br /> _Foundation Pe y_ <br /> FILTER BED n Vista ni eao-nearest: __W.eil _ <br /> Sire Number <br /> SEEPAGE PITS 11 Depth P[operfy Line <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS:. ❑ <br /> ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this applicat <br /> ' rules and regulations of the San Joaquin County <br /> Hama owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, k s a not <br /> Y compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workmen's <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued;I chalk employ persona subject to workman's compensa <br /> tion laws of California." <br /> ust call f r all r fired inspections. Complete drawing on re arse side. <br /> The ap - �el <br /> it!.>j' Date:Title-- <br /> Signed Title:..- Y <br /> F DEPARTMENT USE ONLY <br /> Bate rea <br /> Application Accepted by p <br /> ,� Final Inspection hv�4 <br /> Date a <br /> l _Pit•or out In psction/by� Rate — <br /> f 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 0 Box 200,vi Stkn, CA 85201 <br /> k FEECK RECEIVED By ATE PERMIT N0. <br /> a INFO AMOUNT DUE AMOUNTEREMIMDEH 13-21[REV.1"61 `� .001 , / <br /> EH 11.26 <br /> I <br />