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SAN JOAQUIN COUNTY PUBLIC HtALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> iM f P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Servfcee. <br /> JA-.A ' <br /> Job Address City Lot Size/Acreage <br /> Owner's Name LC-)q 1-cl F` Y, { Z_ Address Phone <br /> � C <br /> [ I <br /> �antractor �� A s cense No. - Phone��f Z <br /> TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT .. DESTRUCTION 0:-Out-of Service We11 ❑ <br /> PUMP INSTALLATION S SYSTEM REPAIR El OTHER ❑ _Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA FLO. PROP-LINE <br /> ''ter FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS. <br /> I <br /> INTENDED USE ' TYPE OFELL�Pfi06LEM1 AREA— CONSTR(JCTION-SPECIFIC-ATIONS— <br /> `Cl 1 ustrial O Open Bottom 0 Manteca Dia. of Well Excavation / l Dia. of Well Casing <br /> Omastic/Private C] Gravel Pack C7 Tracy Type of Casing_ -� I Specifications <br /> I'l Public l.i Other F fl Delta Depth of Grout Seal T <br /> ype'of Grout <br /> I I Irrigation Approx, Dept I i East rn Surface Seal Installed by �` I <br /> Repair Work pone �,U' Type of Pump P. <br /> State Work D <br /> Welt Destruction ❑. Well Diamet r Sealing Material & Depth I s <br /> ' Depth Filler Material & Depth s' <br /> TYPE OF SEPTIC WORK: • NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i,INo septic system per if public sewer is P- <br /> a4lable within 200 feet.) <br /> Installation will serve: Residence (Commercial_ Other t •' ��""VVV <br /> Number of living units: Number of bedrooms ~ <br /> Character of soil to a depth of 13 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT.❑ r <br /> t Method of Disposal <br /> Distance to nearest: Well Foundation Pr' y Line <br /> f <br /> LEACHING LINE Q No. & Length of lines Total length/size ! i <br /> FILTER BED 0 Distance to nearest. Well Foundation __, Property Line. <br /> SEEPAGE PITS I I Depth Size Number l <br /> SUMPS Ll Distance to nearest: Well-- Foundation Property line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and rha't the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations ofrthe San Joaquin County �.,�T k <br /> Home owner or licensed agetit's iignaiure-certifies the following: "I certify that in;the performance of the worstfQr which this permit is issued, I shall net <br /> employ any person in such manner as to become subject to_wprkman's compensafion laws of Calif ornii." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cert' that.in the performance of the work for which this permit is issued, I shell employ t <br /> tion laws of California." .-_ �..f+:'; ., fa ., P Y Persons subject to workman's compensa- <br /> -`� ! t <br /> The applica st c fora 2edin poplions. Complete drawing on rave side.- <br /> Signe Title: <br /> _ � � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 2-A res <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P_Q ox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE I AMOUNT REMITTED CK RE IVEp Y ATE PERMIT'NO. ' <br /> • EH 13-241REV.t/MSI 00 <br /> EH 14-26 �JX <br /> r <br /> L <br />