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I <br /> 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 <br /> coo toSanwithuin SanCJoaquinfor <br /> Countypermit <br /> ordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe <br /> Rules end Regulationsdescribed. <br /> of SanThis <br /> application is made in compliance <br /> Joaquin County Public Health Services. <br /> Job Address <br /> � LLn �gA-4-pel City Lot Size/Acreage <br /> Owner's Na:42�� <br /> Contractor [ Address l' P � Phone e Address License No. Phone S -� <br /> TYPE Of WELL/PUMP: NEW WELL ID SYSTEM <br /> REPLACEMENT C7 DESTRUCTION Cl Out of Service well 7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing_. Specifications — <br /> [:] Domestic/Private ❑ Gravel Pack El Tracy Type of Grout <br /> Casing- <br /> 11 Public I--1 Other fl Delta Depth of Grout Seal <br /> i I Irrigation ­Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done i1 Type of Pump H.P. State Work Done <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material & Depth <br /> — It lor <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION available septic systithinem <br /> rented if public sewer is <br /> eet.1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI 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, an <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 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> R E &Y <br /> Application Accepted by Date �` Area O <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <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 /> Z[I,U NT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24[REV,I/A5) � - t • ��� �� <br /> EH 14.16 <br />