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SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES r>'V <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> 445 N SAN JOAQUIN, ,PHONE (209)46$-3420 1 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Pules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address <br /> Cl/p �� City Lot Size/Acreage <br /> lr�� <br /> u i A ss �er�s Phone gg <br /> Owner's Name lJ 7 <br /> Contracto <br /> d l�� ! +gym/, Address /,) cense No. 306 7 Z Phone SFS ZaYg <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION o Out of Service Well N Monitoring Well ❑ <br /> C7 �\ <br /> PUMP INSTALLATIIO - SYSTEM REPAIR 0 OTHER G r <br /> DISTANCE TO NEAREST: SEPTIC TANK _/C7i'J_t SEWER LINES DISPOSAL FLD. PROP. LINE _3_!L__ <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYff OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial pan Bottom G Manteca Dia. of Well Excavation Dia. i f Well Casing <br /> Gestic/Private G Gravel Pack G Tracy Type of Casing_ Specifications_ �b -- <br /> i'I Public 1-1 Other f-1 Delta Depth of Grout Seal 0 Type of Grout <br /> I I Irrigation —App(ox. Depth )I I Eastern Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P. State Work Done <br /> Well Destruction G Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material S Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> w Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Y " Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER RBED G Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS t I I Depth Size Number <br /> SUMPS L1—Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS G m <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 laws of California." <br /> The applicant must Il for required inspections. Complete drawing on reverse side. <br /> Signed X Title: > _ Date: � > <br /> �O SE ONLY <br /> Application Accepted by Date 2- Area d <br /> Pito nspection by <br /> Date Final Inspection by Date I <br /> Additional Comments: J <br /> AL <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVE BY DATE PERMIT NO. <br /> INfO_ <br /> . EH 13.24 IREV.1iHs1N7t�� 49 <br /> EH 14-2a r <br /> s � <br />