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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 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 I <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 \ / City Lot Size/ c e <br /> Owner's y <br /> (4=2_, 6P <br /> Name �� Address 4/, 6P f4 ` Phone - � �7 00 <br /> FContractor Ntr 1 S rC ' Address t , (801.1747License No.J'2?- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑,Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p' Monitoring Well <br /> i 1 y I <br /> DISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l <br /> "FOt7NpAT14N _ AGRICULTURE WELL OTHER WELL PITSySUMPS <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA. CONSTRUCTION-SPECIFICATIONS i <br /> ,n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11),Domestic/Private.. 'r N, ❑,Gravel Pick 0 Tracy we.of Casing_ Specifications �E <br /> I'} Public Ll_Other fl Delta Depth of Grout Seal Type of Grout t� i <br /> >I I irrigation "§ 4' �..Approx. Depih�t I Eastern F �Lrface Seal Installed by f <br /> 'Repair Work Done L7 Type of Pump " "� H.P. -�—'f <br /> State Work Done_ f U <br /> Well Destruction ❑ Well Diameter .^ Sealing Material 8 Depth t 1 <br /> Depth { �"' --Filler Material & Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAI ODbTION I I DESTRUCTION 17 fNo seplic system permitted if public sewer is <br /> ,!= available within 200 feet.l Q <br /> ,Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: O/ ^/�1 '� ; �Q <br /> Wa <br /> • ter table depth I <br /> SEPTIC TANK O Type/MfgCapacity pia No, Compartments <br /> PKC. TREATMENT PLT. ❑ <br /> e" Method of Disposal / <br /> F Distance to nearest: Well Foundation Property Line k <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth ie_ '2)C I <br /> Number <br /> SUMS Lt Distance to nearest: Well Foundation 1,0& Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatipn 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 aigna`ture 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 riuch manner as to become subject to workman's-compensai ion laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cenify 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 applicants call or I required inspections. Complete drawing on reverse side, <br /> Signed X _ -F—+ .Title:-= - ��' <br /> • ._..-, �. Date: <br /> FOR DEPARTMENT USE ONLY <br /> A cation <br /> Ace td byz=�_.._„ Date /�_ 7�c <br /> ` d-_2- Area <br /> o Grou by Ji` ate V,:=!oL,2- Final Inspection'by izqpat I <br /> r <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 0 Box 2009, Stkn, CA 95201 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT'N0. <br /> CASH <br />. EH13•I4IHEV.iinsr / 7—,/Y <br /> EH 4<-]e <br /> n , <br />