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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 1 <br /> I <br /> PERMIT EXPIRES" l 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. <br /> Job Address ZA <br /> ~� PJ� City 4 GiAZ�+� Lot Size/Acreage <br /> Owner's Name Ile- 4 2'10eoa_ Address Phone <br /> Contractor "1- 61Ll C5;, Address �� 2AP /"yTAC ai� License Na 9 � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR] OTHER ❑ Monitoring Well <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 SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ea <br /> Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications <br /> !'1 Public 1-1 Other t-1 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation —Approx. Depth I I Eastern ­-Surface Said Installed <br /> Repair Work Done 0 Type of Pump H.P. { +• State Work Done <br /> Well Destruction ❑ Wolf Diameter Sealing-Material & Depth �w <br /> Depth ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION INo septic system permitted it public sewer Is V i <br /> �+ available within 200 feet.) • <br /> Installation will serve: Residence.(r'!/ Commercial Others r <br /> ,t <br /> Number of liiving units: Number of bedrooms <br /> Character 1of.sail to a depot of 3 feet':'_ Water table depth IF <br /> SEPTIC TANK D Type/Mfg. Capacity. No. Compartments <br /> J01- <br /> PKG. TREATMENT PLT. Clit a• % Method of Disposal <br /> Distance to nearest: a Well `�� Foundation ��� Property Line <br /> r T <br /> LEACHING LINE ❑ No. & Length of lines - ~` Total length/size <br /> o� <br /> FILTER BED ❑ Distance to nearest: Well�i � Foundation 0_5�!�-77Property Line <br /> SEEPAGE PITS V< Depth Size _M Number _4!91 <br /> SUMPS U1 Distance to nearest: Wel✓4d Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and ihat 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: "t certify that in the performance of the work for which this permivis"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 /> ceriifies 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 requir in r. <br /> tions. Complete drawing a side. <br /> Signed X 4le Title: Date: <br /> OR EP T_ USE ONLY <br /> Application Accepted by Date Argo'-o�fZ <br /> Pi or Grout Inspection by Date✓Final Inspection by Date 12&`9 <br /> Additional Comments: -� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> ` <br /> IF <br /> O AMOUNT DUE AMOUNT REMITTED C - RECE VED BY TE PERMIT N0. <br /> • EH 13.24•iREV.1/.n.5I — <br /> EH i4.2a t <br />