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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 RegulationB of San <br /> Joaquin County Public Health Sery4ces. " <br /> � <br /> Job Address v Cityb+) Lot Size/Acreage <br /> ner's Na Addres <br /> Phone <br />[I 1 Cants c o3 �r " dd� s / Licen e No. (U hone <br />` TYPE OF WELL/PUMP: NEW WELL 4f, WELL REPLACEME ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> I Monitoring <br /> PUMP INSTALLATION ❑ _ SYSTEM Monsters REPAI OTHER 0 ng Well G� <br /> 'DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES r <br /> i PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ii <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT40NS , h <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_. �" Dia. of Wel!'-Casing <br /> DymesticlPrivate ❑ Graves Pack El Tracy Type of Casing Specificf+ <br /> �i'1 Public I. Other (I Delta Depth of Grout Seal Type f Grout <br /> I I Irrigation — Approx. I I Eastern Surface Seul Installed by <br /> Repair Work Done LJ Type of Pump H.f -- State Work <br /> Material ling ;E Depth s92 2124 <br /> Well Destruction ❑ Well Diameter Sea ,-• , <br /> Depth Filler Material t: Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> 'ayailable within 200 feet.) <br /> 4 <br /> Installation will serve: Residence— Commercial__ Other j `" !I" t <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` t (� <br /> vs <br /> LEACHING LINE ❑ No. & Length of lines Total length/sizer F <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line "^ <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest- Well Foundation Property°Line- <br /> t <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 agents 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 r'"ll`nei-as,to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartifies 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 I ." <br /> The applica Attu c uked' spactions. Complete drawing on r rse si <br /> S gne w Tit Dater <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 21 Area .Z <br /> Pit or Grout inspection by Date Final Inspection by Date <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, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT RSMI7TED CK RECEIVED BY DATE PERMIT'NO. <br /> CASH <br /> INFO .� 1 <br /> EH 13-24 IREV.r i n st P (�-\�t7D �f7 C7 R S9 <br /> EH 14.2E !!" J <br />