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1 <br /> 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) I: <br /> Application is hereby rade 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> __ �jlGsl Size/Acreage <br /> Job Address �j Lam` +.� City <br /> Owner's Name <br /> Address Phone <br /> i <br /> Contractor <br /> LLC Address ! ^License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT I7 DESTRUCTION Cl Out of service Well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION ElSYSTEM REPAIR L1OTHER ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE € <br /> } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial -'ti 0 Open Bottom C I Manteca Dia. of Wall Excavation � M Dia. of WeII.Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ $pecificatio"ns• <br /> Type of Grout <br /> I'l Public 1-1 Other ❑ Delta Depth of Grout Seal i <br /> I I Irrigation{ _Approx. Depth I 1 Eastern Surface Seal Installed by <br /> State Work-Oone-�-��'•.""""'"' <br /> Repair Workl Done U Type of Pump— �- ^ """H•P:" -""'^ r' <br /> & <br /> Well Destruction ❑ Well Diameter Sealing Material Depth + <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( I DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> ,f aijaiiable within 200 feet.) <br /> Installation will serve: Residence! Commercial____ Other_ I , <br /> f Number of living units: _�— Number of bedrooms C f 6 �� t <br /> Character of soil to a depth of 3 fleet 'S A) star table depth <br /> SEPTIC TANK C] Type/M{g'�`�� �-' � Compartmenla— <br /> PKG, TREATMENT PLT. Gl " `� Qo Method of Dispose <br /> ' Distance to nearest: , w We 11 Foundation Properly Line <br /> LEACHING LINE "b. &Length ot'lines 1-7 Total length/size <br /> FILTER BED LI Distance to nearest: Well ^Foundation " —PtopertV Line <br /> SEEPAGE PITS ylel Win -Size Nurer <br /> JJ►► <br /> SUMPS -Distance to nearest: V4�ell Faundatiiyn Property Line <br /> r 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 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 fo 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." 1 <br /> The applicant must'call. to all r sired in pections. Complete drawing on reverse side. <br /> Si nad -_ ' Title�z - — Date: "�'3_��.— -- <br /> g f <br /> OR.DtPARTMENT USE ONLY G t <br /> Application Accepted by <br /> Date / 3 i Area l J <br /> € Pit or Grout Inspection by Date Final Inspection by Date <br /> 1 <br /> Additional Comments: <br /> i Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> �. . 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> L FEE AMOUNT DUE AMOUNT REWTTED, ._ .�. CKRECEIVED Y. _ _DAT.E.- RERMI N0. . _ J <br /> -INFO, - CASH" <br /> . EH 172 <br /> EH 11.20 <br />