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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 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 Rules and Regulations of San <br /> Joaquin County Public`Health Services) (aw, ` It ? f <br /> Job Address �� <br /> �r P� CityWC,7 Lot Size/Acreage-A3y -K 1 <br /> Owner's Name <br /> - Address S S E?A av e- Phone ?B2 —/,o$T- <br /> 6, <br /> � an2-iNo.�8�6a3Phoneg 23 <br /> Contractor�O Address g2 License I <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEJt ❑ Monitoring Well �� <br /> DISTANCE TO NEAREST: SEPTIC TANK If SEWER LINESt�II +— DISPOSAL FLD. 1 b ROP. LINE 1/ <br /> FOUNDATION — AGRICULTURE WELL OTHER WELLL40L� PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION4,1 <br /> C1 Industrial ���❑...,,,���,,,Occcpen Bottom ❑ Manteca Dia" of Well Excavation_ Dia. of Well Casin <br /> Domestic/Private �#ruravel Pack ❑ Tracy Type of Casing Specification Q <br /> 11 Public !" Other Cl Delta Depth of Grout Seal Type of Groutt <br /> I I Irrigation A&A Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Su _ H.P. _f State Work Done F <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION 1 I DESTRUCTION l 1 (No septic System permitted it public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms '- <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. ❑ J Method of Disposal W <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation { P.ropeny.Line <br /> F <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, ! she 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." 4 <br /> The applicant rn t call f r alt to inspec ions. Complete drawing on reverse side. <br /> Signed X Title: Or^ Date: <br /> -192 <br /> - <br /> 5FWbEtWIME ONLY ,s <br /> Application Accepted by } Data Area Jf2 <br /> Pit or Grout Inspection by I ! Date (U nal Inspection by Date? !J <br /> Additional Comments: 0 ! a 1 �d 112 <br /> Applicant - Return all copies to: San Joaquin Coun ublic Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY BATE PERMIT'NO. <br /> INFO '7 / /,yy I �i ��yy <br /> . EH 13.24 iAEV.F i n SrVP` / y / / 'f� `� 9 " � <br /> EH t4la V ��/` ffO <br />