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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 /> ��lapv_ (Complete in Triplicate) r <br /> i <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This r <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. p n� <br /> Job Addre �' - Ltd Cit of Size/Acreage <br /> Owner's Nam U1 Address Phone <br /> �66 <br /> � �/ IL 7 <br /> Contractor '� �`� dress Q ` ��license No. Q6 V hone ~r <br /> TYPE Of WELL/PUMP: NEW WELL 13. WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ (� <br /> PUMP INSTALLATION SYSTEM REPAIR 11 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 SPECIFICATIONS <br /> n Industrial ❑ Open Bottom Cl Manteca Dia- of Well Excavation Dia. of Welt Casing <br /> CI Domestic/Private ❑ Gravel Pack 0 Tray Type of Casing_ Specifications <br /> 1'i Public i-1 Other l-1 Delta Depth of Grout Seal pe of Grout <br /> 1 i Irrigation Approx, Depths II astern �a Surfgce Said Installed by <br /> Repair Work Done Type of Pump H.P. I State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted if public sewer is <br /> - available within 200 feet.i <br /> Installation will seine: Residence: -,Comr-rier6al_' Other <br /> Number of living units: Number of edrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line All } <br /> LEACHING LINE ❑ No. & Length of lines Tot-al-length/size <br /> FILTER BED ❑ Distance to nearest: /t ,�_ undlafion Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS N:,L1` Distance to nearest: Well T Foundation Property Line <br /> DISPOSAL PONDS 0 <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 regulati San Joaquin County <br /> Home owner Icense d age 's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> empty 6anyrsoner as to become subect orkman's compensation laws of Cslilornia." Contractor's hiring or sub contracting signature <br /> certifieshat in the ormance f e work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion lawThe appquir a rng on si <br /> Signed Title: v Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by CQCch_-�_s`i aO _ _ _y Date Area C> A <br /> Pit or Grout inspection by Date Final Inspection by Date 1 `3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 .rte <br /> r INFO AMOUNT Due AMOVNT REMITTED CASH RECEIVED 8Y DATE PERMIT-NO. <br /> s EM134 iREV.i/n3( ��C' <br /> EH ta•26ffpg " <br /> r <br />