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i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 + <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> _1 <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 1662 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. w <br /> City Lot Size/Acreage <br /> Job Address we . p ^ <br /> Address <br /> kOwner's Name f 1 ^ Q <br /> I l r` 1 .�' �0 �` I iceOnse l -383Phon �� <br /> Conttactor t/ � f ddress <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT 7 DESTRUCTION Out Of Service well 0 <br /> Cl Monitoring Well C7 <br /> PUMP INSTALLATION © �, SYSTEM REPAIR C7 OTHER <br /> DISTANCE-TO-NEARESTr-SEPTIC`TANK"^"^"""'^"""`-a-rSEWER`LINES <br /> -4 ..t�_. ` •:'DISPOSAL-FtD.- .. ..."_'".PROP:-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> 0 Industrial CJ Open Bottom..w,.- ❑ Manteca is. of Well Excavation <br /> l Domestic lPrivate Cl Gravel Pack; ❑ Tracy Type of Casing_ <br /> Specifications <br /> C7 Other ,' n Delta Depth of Grout Seal Type of Gil. <br /> l Public r <br /> I i Irrigation" ,.: ,—.Approx..Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of-Pumps — H.P. "�Y tate Work one <br /> �Sealing-Mdterial-&_.D.epth' _t7Ak <br /> I Well Destructi6n --)(—Well-Diame er- � <br /> t a Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> _available within 200 feet.) <br /> i <br /> Installation will server Residence_ Commercial^ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a.depth of 3 feet: I i Water table depth <br /> SEPTIC TANK. © Type/Mfg Capacity No.-Compartments <br /> PKG. TREATMENT PLT. ❑ k I Method of Disposal' { <br /> I # <br /> Distance to nearest: Well Foundation j .Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size = <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> r <br /> SUMPS Ll Distance to nearest: Well Foundation 1�_-- <br /> Property Line ; <br /> DISPOSAL PONDS CZ <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 <br /> ounty„_.—.-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 t6 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." I <br /> The applicant must call for all reguired.inspePtions, Eomplets drawing on reverse side. ; <br /> mss, a <br /> Signe <br /> Title: ��� - Date: <br /> rill — <br /> DEPARTMENT USE ONLY <br /> D �j <br /> Application Accepted by _ ate [� -= <br /> f <br /> 1 Pit or Grout Inspection by date Final Inspection by Date <br /> r <br /> r Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> R Environmental-Health Permit/Services <br /> 445 N San Joaquin, P 0 Box, 2009, Stkn, CA 95201 >` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N0. <br /> . EH13-21IREV.tiNSi �INFO 11 ' <br /> t4dq <br /> EH 1.20 W <br /> 1 <br /> V <br />