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SAN JuAQUIN COUNTY PUBLIC HEALTH SERVICES Naw <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> D <br /> P 0 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 Regulations of San j <br /> Joaquin County Public Health Services. <br /> Job Address 0- City ��y Lot Size/Acreage <br /> Xowner's Name Address 1")s� ry S, _ Phone <br /> Contractor Ow Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME=NT n DESTRUCTION ❑ out of Service Well Cl <br /> PUMP INSTALLAT SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ `_ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD, PROP. LINE ► <br /> FOUNDATION AGRI T ELL' � OTHER WELL - PfTS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROB REA CON N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Grt1v ❑ Tracy Type of Casing_ Specifications <br /> I-I Public 1-1 Other I n Delta Depth of Grout Seal Type of Grout i <br /> I I irrigation ^.Approx.'Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth t Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> z ; available within 200 feet.) ; <br /> Installation will serve: Residence_ Commercial <br /> E: <br /> Number of living units: I Number of bedrooms <br /> Character of soil to a depth of 3 feet: ��t ta, Is depth <br /> - <br /> SEPTIC TANK C] Type/Mfg7 'F3a '{rlo, ompanmenta <br /> PKG. TREATMENT PLin T. 0 ��• ��� � �d of Disposal <br /> or <br /> Distance to nearest: Well , ion <br /> LEACHING LINE L"1 No. & Length of lines "' Total length/size <br /> FILTER BED LI Distance to nearest: Well Foundation Property Line ; <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t 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 {I <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, E shalt 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 compansa- <br /> tion laws of California." *� <br /> Thelcant ust call for all r uire spections. Complete drawing on reverse side. <br /> _ n ^ q a <br /> )1�19n:dpl(j <br /> Title: 6 w� Dater <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date - �-- Area <br /> I <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 O Box 2009, Stkn,tCA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK a RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> Eu 13-25 tREV.t i n s( 7 <br /> EH t4•1a -0 4 <br />