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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMFditAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)465-3420 <br /> P O BOX 2009, STOCKTON, CA 9520 . <br /> c.. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � P42 (Complete in Triplicate) <br /> Application is hereby made to San Aaquin County for a permit to construct and/or install the work herein described. This I <br /> application is made in compliance with San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and"Regulations of San � <br /> Joaquin County Public Health Services. � 6 <br /> Job Address City ! Lot Size/Acreage <br /> � 1 <br /> Owner's Name r Address �'[• �7 1`�Phone �7 f <br /> ' Address 7 License 22,L(1.TQ—P <br /> Contractor hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION Cl Out of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRX OTHER ❑ <br /> 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 C3 Open Bottom ❑ Manteca Dia. of Well Excavation -- Dia. of Well Casing <br /> Type of Casing— Specifications <br /> DomesticlPrivate Ci Gravel Pack L7 Tracy yP g- <br /> I Public f-1 Other I-] Delta Depth of Grout Seal Type of Grout <br /> FI <br /> I I Approx. Depth I Eastern5u ce Seal Installed by <br /> �-� <br /> Repair Work Doris Type at PumP'5M1&= H,P, State Work Done 10 i <br /> Well Destruction ❑ Well Diameter ' Sealing tenial & Depth <br /> t Depth t Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is , <br /> ---__---available-within 290-feet.1,14 <br /> Installation will-serve: Residence Comercia _Othe� <br /> Number of living units: '._Number of bedrooms <br /> Character of soil to a,depth iof 3 feet: I Water table depth <br /> SEPTIC TANK ;' ❑ Type/M19 f""* w " Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ I . Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE' 0 No. & Length of lines Total length/size <br /> FILTER BED [_1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth i l Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 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 wort[ 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 ifi t g:he following: "I certify that in the performance of the work for which this permit is issued, I shall employ Oersons subject to workman's co ensa- <br /> tion lawsof Calif 401 <br /> The al pliVAV1W must c for all required ins ions. C plate drawing on revefw4ide. r <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I b � <br />" Application Accepted by � � Date � res <br /> w <br /> Pit or,Gro6t lnspecvi n by, . Date Final Inspection Data <br /> Additional Comments: <br /> t. Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin Box 2009, Stkn, CA 95201 <br /> r <br /> FEE AMOUNT OVE I. AM UNT REMITTEtJ CA R EIVED 8Y O TE PERMIT NO. <br /> INFO <br /> . EFrt3-24;REV.Iinsr � <br /> EH,14.26 <br />