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4 R ' 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 made,to Sass Joaquin County for a permit to Construct and/or install the vork herein described. This <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. <br /> Job Address _ � ! '✓�� � �— City�_ g2v_ t Size/Acreage <br /> Owner's NamJ.1AJPA yAddress /V ?0 " Phone <br /> Contratlor' ��=' Address ? ' " 2 :cense lVt> Phone-... " <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION L-) outof service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER 11 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINESDISPOSAL_FLD; PROP. LINE <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL <br /> PITSl5U <br /> MPS <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) industrial [DOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (a DomesticJPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications. - --- <br /> VI Public FI Other r Delta Depth of Grout Seal Type of Grout <br /> t I Ifnig ation Approx. Depth I 1 Easter Surface Seal Installed by <br /> Repair Work Done U Type of-Pump H,P. State Work Done <br />'4 Well Destruction. ❑ _r Well Diameter Sealing Material & Depth <br /> 4 ll, - Depth Filler Material 5 Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> available within 200 feet.), <br /> i <br /> Installation will serve: Residence JE__1`Commerclal_ Other i <br /> .. r <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a diIII of 3 feet: _ Water table depth <br /> SEPTIC TANK Type/Mfg -- _ Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> l Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lints'"" " t Total length/size <br /> F FILTER BED ❑ Distance to nearest: Well Foundation '"Property Line <br /> SEEPAGE PITS I I Depth Size' Number <br /> SUMPS LI Distance to nearest; Well'_ Foundation Property Line' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this tapplication and tha.i the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> P rules and regulations of the San Joaquin County' r <br /> Home owner or licensed agent's signature certifies the following:-'­I certity thaf ifi the performance of the work for which this permit is issued, I shall not <br /> employ any person in such Mannar 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 laws of California." <br /> The applicant must call for all ired inspections. Complete drawing on reverse side. _ <br /> Signed X <br /> Title: Date: �j <br /> FOP*EPARTPWNT USE ONLY <br /> Application Accepted by Date Ar <br /> Pit or Grout Inspection by Date Final Inspection by� <br /> Date <br /> t r , <br /> Additional Comments: <br /> k � ; <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> an loaqulii;�P O Box 2109,•Stkn, CA 95201 <br /> AMOUNT DOE` <br /> AMOUNT fttEMiTTEf3IW�RECEIVED BY DATE PERMIT NO. <br /> INFO 1 ,y <br /> . EH 13-14 It1EV.t i n 5l 'r Q l ..J <br /> E!1 14.26 <br /> L <br />