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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ma,de,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> j application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin.County•Pglic-Health Services. <br /> i N S I3 y Lot Size/Acreage <br /> Job Address- KU2 C/7� ST L! �L 7 __ Cit <br /> Owner's Name - <br /> G/ QDI _ Address Phone <br /> ontraC10( '/ter / - Address ��x License too, a5�7Z3 Phone <br /> T PE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 111 Out or Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER 0 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 SPECIFICATIONS ` <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing N <br /> C.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing— <br /> £w Specifications <br /> C1 Public is Other n Delta Depth of Grout Seal' Type of Grout <br /> i I Irfigation �.Approx. Depth I I Eastern Surface Seal Installed by f <br /> Repair Wo'rk Done LJ Type of Pump H.P- State Work Done w <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> i <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REi I DESTRUCTION INo septic system permitted if public sewer is _fn <br /> vailable within 200 feet.l <br /> Installation will serve: Residence e Commercial_ Other A <br /> Number of living units: Number of bedrooms �. t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Tw Capacity No. Compartments T <br /> Method of Oit;posak <br /> PKG. TREATMENT PLT.❑ 1 ' v <br /> Distance to nearest: Weil foundation Property Line <br /> k <br /> Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines g <br /> FILTER BED ❑ Distance to nearest, Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number t <br /> i SUMPS L.1 Distance to nearest:� Well Foundation Property Line <br /> 1 <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 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 /> The applicant must call for required inspections. Complete drawing on reverse side. <br /> / /C! t=Cr/�- X <br /> ' Signed X �// cn� - _.- Title: Date: <br /> F R DgPARTMENT USE ONLY <br /> Application Accepted by a4A Date <br /> � � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data�.Z <br /> Additional Comments: <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOU T A±TTEDCASH RECEIVED BY GATE PERMIT NO. <br /> INFO <br /> r1 <br /> . EH 1 <br /> 3-21IREV.Iiwsi U.-Zt� <br /> Eh t4-25 40 7 <br /> sp <br />