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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 0 BOX 2009, STOCKTON, CA 95201 ! <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <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 1662 and the Rules and Regulations of San <br /> Joaquin co Services. <br /> lKfeff!w ' �� <br /> Job Addre City Lot Size/Acreage I <br /> Owner's Name Address Phone <br /> Contractor Address <br /> t License Note Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E DESTRUCTION ❑ Out of Service Nell C1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI industrial ❑ Open Bottom 10 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_- Specifications <br /> 1'1 Public 17 Other 4n Delta Depth of Grout Seal j Type of Grout <br /> I i Irrigation _,Approx. Depth I 1 Eastern Surface Seal+Installed by ' '~ <br /> t r <br /> Repair Work Done 01 Ty f Pump H.P. State Work Done S <br /> Sealing Material & Depth ; <br /> Well Destruction O Weil' Diam r e ! ' <br /> Depth ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIRIADDITION I I DESTRUCTIO (No septic sys permitted it public sewer is �+ i <br /> Zavailable 200 feet,I <br /> installation will serve: Residence— Commercial Other Number of living units: Number of bedroomsble depth lVll J <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Cl Type/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT. 0 � Method of Disposal 5 <br /> Distance to nearest Foun Well Property Line <br /> I t 2 <br /> LEACHING LINE 0 No. & Length of lines I oral length/size' <br /> FILTER BED ❑ Distance to nearest:! Weil Foundation Property Line l <br /> i F <br /> I <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to est:}' Wait Foundation ' Property Lind <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have preps this application and that the work will be done in accordance with San Joaquin county or nces, state laws, and <br /> rules and regulations of the S Joaquin County t <br /> Home owner or licensed nt'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 /> rkman's com nsa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to wo pe <br /> tion laws of California." 1 10 <br /> The applicant must call for all uir inspections: 9,mpl a drawing on reverse side. �q <br /> Signed X Title: Date: v <br /> FITMENT USE ONLY 7) <br /> w <br /> Application Accepted by -7-30 Date -`� Area <br /> Pit or Grout Inspection by Date T� Final Inspection by % UJ Dateu�- <br /> Additional Comments: 1 75 <br /> Applicant - Return all copies to: San Joaquin County Public Health ervices <br /> Environmental Health Permit/Services a> <br /> 445 N San Joaquin, P a Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�(r <br /> . <br /> INFO �7� j/�� �J +7 r�/EN r3-24 ItrfV.l i e 5i L a, Lft-t9t 3 V �Y� C !D"- <br /> EH 14.2E -71 <br />