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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <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 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 <br /> Joaquin County PublicHealthHealthServices. <br /> 0 d �+ City Lot Size/Acreage <br /> Job Address 1_0 Ir <br /> Owner's Name! f/`�•4._V -- Address Phone r <br /> �C.ontractor g�Cl ( � Address ,6 !?V 17 4? License No. ?AFr_Phone 2�"2 LJ <br /> TYPE OF WELL/PUMP: LL-NEW 1.WELL WELL REPLACEMENT F1f' DESTRUCTION 01-Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C3Monitoring well 0 { <br /> DISTANCE TO NEAREST: SEPTIC TANK j SEWER LINES DISPOSAL FLD. PROP. LINE_ ! <br /> :•'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE!OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [) i <br /> Cl Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi <br /> 3'A. 4> <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing— pa%C Specifications <br /> 1'1 Public 0 Other f-1 Delta Depth of Grout Seal D Ty a of Grout._ <br /> i I Irrigation '3 ;e_ Approx. Depth I 1 Eastern Surface Said Installed by <br /> Repair Work Done L] Type of Pump SILO& H,P. _ 3 State Work Done_12216t S��t4 yT <br /> Well Destruction ❑ Well Diameter __ Sealing Material & Depth �} <br /> Depth Flller"Material & Depth I <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I. DESTRUCTION l I (No septic system permitted if public sewer is h <br /> ` r available within 200 feet,) <br /> Installation will serve:-Residence Commercial— Other— <br /> Number <br /> ther Number of living units: Number of bedrooms <br /> Character of soil to vdepth of 3 feet: r Water table depth <br /> SEPTIC TANK' • i ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT.PLT. ❑ i" Method of Disposal <br /> Distance'to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl" No. & Length of lines Total length/size } <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line' <br /> SEEPAGE PITS 11 Depth. Size Number <br /> "LI Distance to nearest: Well Foundation, Property Line ; <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 laws of California." <br /> The applicantsPections. Complete drawing on reverse side. <br /> :Z;Lt: <br /> Signed X Title: Qinn= Date: <br /> TMENT USE ONLY <br /> Application Accepted by Date r Area 2" <br /> Pit or t Inspection by Date 1Q Final inspection by Datez- <br /> Additional Comments: �t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 I San- Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> IFEENFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0, <br /> . EH 3-24(REV. p■ / v'•� + <br /> EH t�•2E <br /> 13 t� I.1 sem ��-�z � z� <br />