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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 O BOX 2009P STOCKTON, CA 95201 X*r Uz& 20 3 r707-0 j <br /> 3<. ERsrL_q-Ke i0E-.,u'. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ti��p� rf� �l,�f PtCo �1� I (Complete in Triplicate) <br /> ­-� .� -_ <br /> Application is hereby me,de`to'San Joaquin County for a permit to construct and/or install the work berein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Jrioh7 S = .152 — 050—O$ / 2.S2 <br /> i r <br /> Job Address City_1 rte' f4' Lot Size/Acreage^ a LAS f <br /> µ <br /> Owner's Name «0 .DaV&-L.. C-00Addressn► hone ���� <br /> t zz68 9 <br /> Contractor�6GTJ'LN-tf►'4 rNF�?Addies s �Z,S �r 1']'1YlL7Z� -r"7+-. License No. � Phone "13 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out -o Ssvk4i� n <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E"'-43 7vs7-&tk& <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PeaC )S <br /> ^INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Bia,Qf Well Casing 6" DI <br /> C I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ gper fT- i ce` <br /> I'! Public S-1 Other # n Delta Depth of Grout Seal +fir f <br /> I 1 Irrigation _ _ —Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ ll7ilf� ll� <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) p� <br /> Installation will serve: Residence-.I Commercial— Other _ -!J <br /> Number of living units: Number of bedrooms O <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ; Capacity----- No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation; Property Line Q <br /> I DISPOSAL PONDS ❑ <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 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 taws of California." #. <br /> k The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 4f_61 +S6a1-oGr51 _ Date: ._ <br /> OR ARTMENT USE ONLY <br /> Application Accepted by Date tea <br /> Pit or Grout Inspection by Date — .final Inspection b Date <br /> Additional Comments: <br /> Applicant - Retu all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> -f. 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO �) CASH r} �p <br /> . EM 13.24(REV,rix 5)J U �(j 312-3 �3^Q%4_6 <br /> EM 14.26 *• <br />