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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �2 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 blic He th S vices. ,,`6 <br /> Job Address r� ' (I City Aw Lot Size/Acreage <br /> /sAZ-0�3 <br /> Owner's Name Address � y Phone <br /> F J W w <br /> Contractor >" ��//�11J ��CAX1 27 S&r ,$ �� Li n No. 237Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION AC SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> C_) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout ^v <br /> rri9ation Approx. Depth I I Eastern rface Seal Installed by <br /> Repair Work Done 0/Type of Pump _ H.P. X State Work Done f,. <br /> �^ <br /> Well Destruction O Well Diameter 12— Sealing Material & Depth `" ) <br /> Depth Filler Material i Depth <br /> E OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is <br /> available within 300 feet.) <br /> Installation rve: Residence_ Commercial_ Other ` <br /> Number of living un1 . Number of bedrooms 1� <br /> Character of soil to a depth feet: star table depth -fJ <br /> SEPTIC TANK O Type/ y No. Compartments <br /> PKG. TREATMENT PLT. ❑ b Method'of Disposal <br /> Distance to nearest- Jindation Property Line <br /> LEACHING LINE ❑ No. & L of lines ngth/site <br /> FILTER BED Cl ance to nearest: Well Foundation Pro ine <br /> SEEPAGE P 11 Depth Size Number <br /> M " <br /> SULI Distance to nearest: Well Foundation Property Line w <br /> POSALPONDS ❑ <br /> I 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 ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> emploRpersuc anner as to becomes a to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifiify that in the rfor n of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laThe all s. Comp) a drawing on re a I �� `Signe Title: _ s� Date: V <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Z.,-- V,_s _ Date —� Ar a o I <br /> Pit or Grout Inspection by Date Final Inspection 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 Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE A/�M[[OUNT REMITTED CAS0CK 0 RECEIVED BY 0 E PERMIT'N0. <br /> . EH 13.241REV.t/NSI t � 7�j c"' JZ3 <br /> �� ' 16 <br /> EH 11.26 111.••JJJ <br />