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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> V\ P O 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 Publ Health Services. /�j <br /> ,�7 City Lot Size/Acreage J i `, <br /> Job Address <br /> (� <br /> Vol <br /> Owner's Name ---L r .�-� Address t� / <br /> Contractor <br /> ttl�dI 'rAddress License No. %19 Phone <br /> or bervice Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [.1 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I"1 Public 1-1 Other f-1 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 O Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 teat.) <br /> Installation will serve: Residence 4 Commercial Other r 1Vi 1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 4K Type/Mfg Z CtLr c:Q_A - E Capacity_.. No. Compartments O <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundafion Property Line <br /> LEACHING LINE *4- No. & Length of lines Totat length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well <br /> fourtdBtfSri' Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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, l 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 /> tioh taws of California." <br /> The applicant st 1 fo I re d-inactis. Complete drawing on reverse side. <br /> Signed X < Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ - Date / a <br /> Pit or Grout Inspection by 77 Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquini P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO (� �,p <br /> . EH 13.24(REV.1/N 51 i� j�l � �Y '� L� f� �✓Z 37 <br /> EH 14.26 i <br />