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[► SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t <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. 'I <br /> Job Address ISKk?��� City .5r0 14(-T&%J Lot Size/Acreage <br /> f <br /> Owner's Name Address Phone <br /> �SyO DKr"3f <br /> Contractor_ TWA) ZAWLI�Y &1 J1A Address //766 _nJ AILf PQSaF License No. &Z S Phone <br /> TYPE OF WELL/PUMP: T NEW WELL❑ /�-_,WELL`REPLACEMENT 0 DESTRUCTION c Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <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 SPECIFiCAT10NS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation_ Dia. of Wel! Casing <br /> I-) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i I'I Public t.1 Other n Delta Depth of Grout Seal Type of Grout \ <br /> I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by <br /> 4 Repair Work Done U Type of Pump 4 H.P. State Work.Done 4�! <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 I DESTRUCTION KiNo septic system permitted if public sewer is <br /> ,y, available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: 11 Number of bedrooms <br /> Character of soil io a depth of 3 feet: W e depth \\ <br /> SEPTIC TANK Z ❑ Type/Mfg a&CCA "TC — Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ation Property Line <br /> r--�.` <br /> LEACHING UNE ❑ No. & Lengt�Iines F Total length/size <br /> FILTER BED ❑ Distance to Foundation Property Line <br /> SEEPAGE PITSDepth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property line <br /> DISPOS NDS C] <br /> I eby 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 °' ' c.; ' <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." ii <br /> Theappli st cal for all required 'nspe ions. Complete drawing on reverse side. <br /> Signed Title: eAdDate: 33 <br /> FOR DEPARTMENT USE ONLY at <br /> Application Accepted by Date �� 1��--- Area j <br /> Date Fina! Inspection by Date 3,(i� 4 <br /> Pit or Grout Inspection by Pe r l <br /> Additional Comments: �! ; �C de- Mows, -4 a S _ <br /> Applicant —Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> si <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. <br /> llTFO /`] <br /> . EH 13.24 10EY.I/K51 l 3 / <br /> EH 14.26 .!f <br />