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y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r <br /> - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ' Application ie hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> k application is made in conpliance with.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' Job Address �_ i� llAZng$� r�q5s Al CityLot Size/Acreage <br /> Owner's Name —a! S - - Address Phone <br /> pp1 <br /> Contractor s g°`, Address �� )PO License No. �� <br /> fiPhone� <br /> ,TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ ° -- ,_SY3TEM_RtFAIR ❑ OTHER ❑ Monitoring well <br /> F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> PflOBLEM,AREA- -CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF;WELL <br /> tC7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' <br /> Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Ci Othern Delta Depth of Grout Seal -_. Type of Grout <br /> I11 Irrigation ____Approxi Depth l I Eastern-.�--- -Surface Seal-Instaued•by---•-Repair Work Work Done U Type of Pump g H.P. State Work Done <br /> Sealing Material i Depth = I v <br /> Well Destruction ❑ Well Diameter f _ <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOW"I I REPAIR/ADDITION DESTRUCTION I l JNo septic system permitted if publis,sewer is W <br /> i available within 200 feet.) <br /> Installation will serve; Residence. Commercial— Other,-­-IN <br /> Nurtlber of living units:, Number of bedrooms 'Y <br /> Character of soil to a depth of 3 feet Water table dep' 71th <br /> SEPTIC4ANK �� Type/Mfg . ' ,Capacity No. Compartments " <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Ll '� V, r Method sPo �! <br /> ,. Distance to nearest: Well _ Foundation Property Line - <br /> LEACHING LINE No' & Length of lines Total length/size <br /> I FILTER BED C) Distance to nearest: Well Foundation �roperty Line <br /> 1 f <br /> SEEPAGE PITS s - I I Depth`: Size r. r Numbir <br /> - SUMPS �isianca to nearest: Well --- Fouridation 42-VP Property Line <br /> DISPOSAL PONDS © •'�„ } lrV,.'t <br /> I hereby certify that I have prepared this'apphcation 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 of 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 cdmpansation laws of California." Contractor's hiring or'sub-contracting signature <br /> cerlifies`tho following: "I certify that in'the performance of the work for which this permit is-iss`ad,,I shall empioy`persons subject+to workman's compensa- <br /> tion laws-of California." <br /> The applicant must call for all equired inspections. Complete drawingrora rave"rso side:,` <br /> ( Signed X ,*" � � ..�� .Title:` `. Date: <br /> ' �% I�FORPARTMENT USE ONLY � <br /> i :.I i <br /> j L <br /> Application Accepted by 0ate Area <br /> Pit or Grout Inspection by Date Final-InsoaCtion by V. Date �- <br /> f <br /> � <br /> Additional Comments: <br /> j Applicant - Return all copies to' San Joaquin County Public-`ealxh-.Sex�,viceS-"' - P <br /> at Environ" ntai Heglth Permit/Services ' <br /> 445 N Sari Joaquin 'P" ii 0" ox 2009, StkCA 95201� <br /> t _ <br /> �. .FEE-- _ ._�. <br /> kNFO 'AMOt7NT DtJE'`;'� `';11MOUNT REMITI`ED'~" "-GK H REL.Gt:IVE�BY,�W.T "DATE AERMl7'NO. �Y ---•�� <br /> � CH 1324IREV '/n51 �� / V� %//�•�_,.,�(�4 - � A �'f r�W[J�J <br /> j EH 14.20 <br /> t <br />