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'x.v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES TH -- 1 <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) E <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 /> f��1 City Lot Size/Acreage <br /> Job Address �j / <br /> Address Phonate` r /�- <br /> Owner's hame q <br /> icense No. � / 7 Phone Q <br /> Contracto Addres � i <br /> NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of service We11 ❑ <br /> TYPE OF WELL/PUMP: <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER ❑ Monitoring Well K <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WfLl PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ezcavajyon <br /> Dia. of Well Casin <br /> tjLType of Casing <br /> Specifications <br /> [I DomesticlPrivate Gravel Pack 0 Tracy Yp g._ ,� Type of Graut <br /> I'l Public CI Othoe� n Delta Depth of Grout- <br /> I I irrigation luAPp►Ox Depth i I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done 0 Type of Pump Sealing Material Depth <br /> Well Destruction ❑ Well Diameter <br /> Dep & Depth <br /> Depth Filler Material p +�f 1 <br /> J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REP available I ! DESTRUCTION I I availablerwi system <br /> 200 permitted <br /> it public sewer is <br /> Installation will serve: Residence— Commercial_ Other <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 <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED Cl ,Distance to nearest: Well Foundation Property Li►m1�19 <br /> Size NumberM4t StRViC <br /> SEEPAGE PITS I 1 Depth int HEPkLIH DNIS`�'�} <br /> SUMPS CI Distance to nearest: Well Foundation Pro <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, 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 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 Jaws of California." <br /> The applicant must call for all required in ctions. Complete drawing on verse side. <br /> Signed X <br /> ..�A� Title: g r Date: <br /> OR DEPARTMENT USE ONLY <br /> Area <br /> Date <br /> Application Accepted by <br /> 2 <br /> Pit o Gr ut spection by <br /> Date n,I 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 O Box 2009, Stkn, CA 95201 <br /> EEE CK RECEIVED BYjD;AITE ] PERMIT'NO.INFO AMOUNT DUE AMOUNT REMITTED HEH 13-21{REV.f i n sl � D <br /> EH 11.14 1 <br />