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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> S°�� n°�"``�"� �°�� 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> YZ, P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in 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 /> LL �� _ _ City Lot Size/Acreage <br /> Job Address -1� <br /> t'3/�om` <br /> a tf el—� r _. ---� <br /> Phone _ <br /> Owner's Name ddress A <br /> A sc- License No. Phone <br /> Contrafor ddress <br /> t <br /> TYPE OF WELL/P MP: NEW WELL D WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service well ❑ <br /> Monitoring Well <br /> PUMP INSTALLATION 13--------- -SYSTEM REPAIR...-/-- � - �--- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ."DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL rOTHER VkLL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS S� <br /> n Industrial ❑ Open Bottom O Manteca Dia. of.WeN Excavation Dia. of Well Casing <br /> ('1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casjng_' <br /> I'I Public � Specifications �ti <br /> I:1 Other t is �' alta Depth ol�Grout Sea. Type of Grout <br /> y r <br /> I I Irrigation Approx. .Depth 1:1rlastern Surface Seul;'Instalfed by <br /> i `l a <br /> Repair Work Dane U Type of Pump H,P, State Work Done� +• �;� a <br /> Seali�rig�Material i depth <br /> Well Destruction ❑ Well Diameter �,• _ a <br /> Depth ; i .._i.'.°°" �'; 'Filler. Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INST ALL + TIOf�,l<,l,1 REPAIR ADDITION , DESTRUCTION I i4. availabpetic <br /> w thin 200 feet.) <br /> e8(No Se . System rt'ed it public sewer is <br /> Installation will serve: Residence Commercial_ Other l- GQ�t C -�r "�v✓ d � �' l <br />'i Number of living units: Number of bedrooms t i <br /> i .; <br /> 1 _ Water table depth O <br /> Character of soil to a depth of 3 feet: I�� � � ` <br /> SEPTIC TANK Type/Mfg <br /> ' 3cit y No. Companments 1!1_ <br />` PKG.-TREATMENT PLT. = f + �Jr e °• ,. Method of Disposal <br /> f, <br /> 4 ance to nearest: Well �Foundation Property Line. .— <br /> t <br /> LEACHING LINE � No. & Length of lines Tot_al tenhlsixe <br /> g- <br /> FILTER BED ❑ D' t nce to ne arest: Weld f oundajion Property,rLineY — <br /> lb <br /> k-1 r,.+ Number <br /> R SEEPAGE PITS ( I Depth r - t Size <br /> ¢ ,. <br /> SUMPS I Distance to nearest: a Well Foundation ',Prgpgrty Lina ` <br /> k DISPOSAL PONDS ❑ is <br /> I hereby certify that I have prepared this application andtthhe work will be dona�n accordance with-San Joaquin county ordinances, state laws, and <br /> at t <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 perforrnignce of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject,to workmansscomgensation-laws of Califgrnii." Contractor's hiring or sub-contracting signature: <br /> cenifiss 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 /> j tion laws of California." <br /> The applicant must call for all re fired inspections. Complete drawing;on reverse <br /> Title: _4k:4 l_ - Date: <br /> Signed X i _ <br /> ^FOR DEPORTMENT USE ONLYIML <br /> ! <br /> Area <br /> Application Accepted by Date 1C <br /> ...ter,_.,. <br /> -- Data _ Final Inspection b Date <br /> Pit or Grout Inspection by _ <br /> o G7 �3G <br /> Additional Comments: dA— <br /> App licant-"--•--Return-"all-copiel't'o: San Joaqu n County Public Health Ser ices <br /> (747 <br /> Enviropmental Health Permit/Services Q <br /> 445,N'San Joaquin, P .tJ Box 2009, Stkn, CA 9520166 <br /> t FEE AMOUNT DUE- AMOUNT REMITTED"" CASH RECEIVED BY DATE PERMIT N0. <br /> - INFO <br /> a <br /> EH 13.24 tREV. L sr S II y <br /> FH 1429 - ' <br />