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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. / �9 <br /> 1/�ddress r 4 �^ f• �`- City M ` Loi Si 2e/Acreage /� �" <br /> Owner's Narry/-,N/ U OVA 7�=PAddress j Q �'ft "a,-T LIU`-Y Phone f f-I-a l Q Y <br /> Contractor S t'L" R Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ('I Public (-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION J! 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: _Z.., Number of bedrooms <� r <br /> Character of soil to a depth of 3 feet C L Water table depth Z <br /> SEPTIC TANK Z1/Type/Mfg Gd Gr 2 Capacity ! Ci a No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disp9sal <br /> Distance to nearest: Well "JL Foundation _ Property Line O <br /> LEACHING LINE ET"­No. & Length of lines �'� S^d TotY length/size 1 CO''E�' <br /> FILTER BED ❑ Distance to nearest: Well____'V6 Foundation SO Property Line <br /> SEEPAGE PITS I I Depth Size--------- Nrmber <br /> SUMPS Lor Distance to nearest: Well o Foundation -O Property Line <br /> DISPOSAL PONDS ❑ if - I0 X *1X9 r _ 2-t3 X Z= r <br /> 1 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 workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required insPections. Complete drawing on reverse side. <br /> SignedTitle: Date: _ <br /> F9R DEP T SE ONLY <br /> Application Accepted by 2 '✓ Date rea oee <br /> Pit or Grout Inspection by ,p r Da a Final Inspection �� Dlt- <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED 14 RECEIVED BY DATE PERMIT'N0. <br /> INFO �CASHEH 1 <br /> • EH 14.Ie tREV. i x sl <br />