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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 /> i <br /> Application is hereby mrsde,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 PublicHealth Services. Q <br /> Job Address <br /> V /q �+�• City A-' Lot Size/Acreage <br /> Owner's Name N Address r �� Phone <br /> f I ' <br /> Contractor <br /> J�('S Y,'C cp Address ' ` �' License No. __Phone Vft-S <br />' TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT n DESTRUCTION ❑ Out of ,Service Well C <br /> f <br /> SYSTEM REPAIR PUMP INSTALLATION ❑ <br /> Cl OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LIN <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> lType of Grout /I <br /> I'I Public C7 Other V"] Delta Depth of Grout Seal SCJ <br /> I i Irrioation _.Approx. Depth I 1 Eastern t 'Surface Seal Installed by <br /> H•P. Z State Work Done I <br /> Repair Work Done U }Type of Pump 1 <br /> Sealing'Ma'terial & Depth <br /> Well Destruction f C3 Well Diameter \, ,. <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC,WORK: Ti I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> r <br /> R available within 200 feet,I <br /> Installation will serve: Residence Commercial Other ' <br /> Number of living units: ..-_ Number of bedrooms sip <br /> t <br /> Character of soil to a depth of 3 feet: t Water table depth. ��/ <br /> SEPTIC TANK ❑ Type/Mfg �"�N,tt?s � Capacity r GO A# No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' r Method of Disposal y <br /> Distance to nearest: Well SOS ;Foundation S♦ Property Line �F 1 <br /> LEACHING LINE No. & Length of lines '3` ga v Total length/size <br /> 7 � <br /> r �` Property Sine $'fi <br /> FILTER BED 0 Distance to nearest: Well 0 Foundation <br /> + SEEPAGE PITS l I Depth Size "� Y �' Nurrtber <br /> I SUMPS ClDistance to nearest:.; !Well Foundation }' Property line <br /> l DISPOSAL PONDS ❑ <br /> this application and that the woik-will.be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared <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 cotnpeensation 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 /> +, <br /> tion laws of Californla." <br /> The applicant must cal! for all required inspections. Complete drawing on reverse side. <br /> Signed � Title:�,rDate: — <br /> i -' <br /> 5 w ..+ <br /> i ? FOR DEPARTMENT USE ONLY�� �� ,ri. a� <br /> Application Accepted by Date Area <br /> " Pit or Grout Inspection by Date Final Inspection by Date 3�`I-93 <br /> LM 4-L AD <br /> Additional Comments: P <br /> Applicant - Return all copies to: San Joaquin County Public Hea th Services <br /> } Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO t ,` (�•� <br /> . EH 13,74 iREV."i++s�s� 1 1 .DQ ` •� �~ �^' �� J �7 D of <br /> EH 14.2E <br /> l <br />