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s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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) <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 /> Job Address .. ��1_,___1_`� v�\\ ` CT _ City.Uz��\ Lot Size/Acreage <br /> C U .` 1 3J �\1 <br /> Owner's Name Address Phone <br /> � 1 <br /> Conlraclor_AAS,\� °� Address N\� lnaLS`SVC\\S�Ati License No Phone <br /> k <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FP DESTRUCTION ❑ Out of Service Well ❑ � <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION"T"�'--"` ` AGRICULTURE WELL" '�"----OTHER-WELL- -PITS/SUMPS <br />" —INTENDED USE TYPE OF WELL -2 PROBLEMAREA. CONSTRUCTION SPECIFICATIONS.- <br /> C! Industrial _ ❑ Operi Boitom ❑ Manteca'• f—I3ia.,of Well•'ExcaVation Dia. of Well Casingi <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ � - Specifications <br /> I'i Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _,Approx. Depth 11 Eastern Surface, sal Installed by Q I <br /> Repair Work Done )4 Type of Pump ��� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth "V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.l dr <br /> Installation will serve: Residence_ Commercial_ Other 4 f <br /> Number of living units: Number of bedrooms <br /> n <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. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines. .-.� -. <br /> g Total length/size <br /> FILTER BED ❑ Distance to nearest. '-Well-- Foundation Property Line <br /> SEEPAGE PITS <br /> 11 Depth Site ./ Number <br /> SUMPS L1 Distance to nearest: ^1Nell �'` °- Foundations. __ Property Line k <br /> DISPOSAL PONDS ❑ j <br />��I-hereby-certify-that I have-prepared this-application that the work-will be done in accordance with San Joaquin-county ordinances,-state-laws;,ander=++ . <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 taws of California." Coritractor'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 empfo`y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required insPections. Compi lie drawl n reverse side. <br /> Signed X_ � �^ _ Title: Date: - � _ r <br /> / <br /> " FOR DEPARTMENT USE ONLY s/ <br /> Application Accepted by Date <br /> "--X., / <br /> rea <br /> Pit or Grout Inspection by Date Final Inspection by ��' Date <br /> I <br /> Additional omrtienti <br /> «.,App,li-sant---Retur-t-allycopies'to: —San4Joaquin�-Counby-Pubi-i-c-!Hea3t-h-9ervtces- <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT <br /> DUE <br /> AMOUNT REMITTED CASH CEIVED BY DATE PERMIT'N0. <br />. EH1324(REV,r/n5) 1,--3-7 <br /> EH 14-2a ff <br /> e f <br />