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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 /> i <br /> PER1dIT EgPIRES•1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is hherebinmade to compliance xolathuSanin CJoaquinounty oCounr a tyrprdlnancemit to nNo. 549struct and1862sand the tall eRules and RegulationsofSane <br /> application <br /> Joaquin County Public Health Services. r� ,V �G <br /> f� /°� � fjs �..,.f�7�ity.•�4x �'" Lot Size/Acreage <br /> q/Job Address + ,,) Address r Phone <br /> Owner's Name w <br /> ✓Contractor ! <br /> Address�,t/e �-} S,T -/'r License No. <br /> �.�--Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well L7 I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] -�� <br /> OTHER ❑ Monitoring Well <br /> PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. iv- <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA' CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> .L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications- <br /> [-1 Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing- <br /> ['I Delta Depth of Grout Seal Type of Grout <br /> I'I Public [-I Other - <br /> I iIrrigation /fist_.Approx. Depth I. Eastern Surface Seal Installed by <br /> of Pump H•P State Work Dane <br /> Repair Work Done U Type [ t� <br /> Well Destruction ❑ Well Diameter Sealing Material & DepthFiller Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION aNaitabPerw thin 200 feeillled if public sewer is <br /> Installation will serve: Residence— Commercial — Otherr y <br /> Number of living units: w Number of bedrooms Water table depth <br /> .Character of soil to a depth of 3 feet: �,,.. No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg �EaPaCity — <br /> .� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line�— <br /> Total length/size <br /> TEACHING LINE F-1 No. & Length of lines Property Line <br /> FILTER BED 11 Distance to nearest: Well Foundation <br /> Numb <br /> SEEPAGE PITS 11 Depth Size <br /> Number <br /> SUMPS Ll Distance to nearest: - Well Foundation Property Line <br /> DISPOSAL PONDS ❑ titZ <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 /> "I certify that in the performance the work for which this permit issued, f shall not <br /> Home owner or licensed agent's signature certifies the following: pensation laws of California," Contractor's hiring or subcontracting signature, <br /> employ any person in such manner as to become subject to workman's com <br /> cartifiss the following: "I cartify 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." <br /> The applic t c i for all required inspections. Complete drawing on reverse side. <br /> V/Signed X <br /> Title: - -— Date: <br /> + F R DEPARTMENT USE ONLY <br /> Area d <br /> Application Accepted by Date <br /> i Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> I Additional Comments: Axwz 4.4 D Q sj <br /> Applicant - Return all copies'to: San Joaquin County Public Health Services \may <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p o Hox 2009, Stkn, CA 95201 <br /> FEE C1C RECEIVED By DATE PERMIT N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> I / A <br /> . fH 53$4{REV,i i�e) 'T D V® dam <br /> Z <br /> fm 14•2e 0n <br />