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I� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> v 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1� jN P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Al I (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 1$62 and the Rules and Regulations of San <br /> X <br /> Joaquin County Public Health Services. �^✓ p <br /> / yob Address il" �—• r✓'f F City ` t� YJ Lot Size/Acreage /. p� 7 <br /> Owner's Name `J +Y✓ I,�+' 'h C 17 fCf //l1 Address r ' (=4fP rr0 `'Oh Phone <br /> Contractor /"Oti �G ` / Address 7 �� 4< r/S/ b1 License No,��6f/r_Phone <br /> TYPE OF WELLIPUMP: 1! NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 SPECIFICATIONS1,'I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing f <br /> C7 Domestic/Private ❑ Gravel Pack? ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public l-1 0141 n Delta Depth of Grout Seal Type of Grout y <br /> I I Irrigation —Approx, bepth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump. H.P. State Work Done <br /> Well Destruction O Well Diameter: Sealing Material Depth <br /> Depth,` Filler Material 4 Depth <br /> �( TYPE OF SEPTIC WORK; NEW INSTALLATION A REPAIR/ADDITION I I DESTRUCTION t I (No septic system peimitted if public sewer is <br /> available within 200 leet.l <br /> II Installation will serve: Residence X' Commercial _ Other <br /> Number of living units: r I� Number of bedrooms 3 - r <br /> Character of soil to a depth of I3 feet: Water table depth ~S� <br /> SEPTIC TANK i Type/Mfg +� _ Capacity Q No. Compartments 2 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well / S Foundation Property Line <br /> II <br /> d <br /> LEACHING LINE l No..I & Length of lines 3 Z rs Total length/size <br /> FILTER HED n Distance to nearest: Well S0 Foundation _ Property Line ZeD <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such stunner 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 oire ins/P�c ion/s. Complete q <br /> �SignedpXcant- ust III ( r all re" '' ,�-'f' —_ drawing on reverse side.Title: 0.Aa1+11-S. _ _ Date: <br /> i Ip ENT USE ONLY <br /> Application Accepted by Date Z Area Q <br /> I 1 r <br /> Pit or Grout inspection by I� Data Final Inspection b Date 9� <br /> I� <br /> I Additional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> f I� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO, <br /> i INFOI <br /> {CASH <br /> . EM 13-24 WV.I/nsi /: // i� r ( 611ori <br /> t EH 14.25 <br /> 1 <br />