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"APPL rCAT I ON <br /> 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 /> . t <br />.: PERMIT FIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) <br /> 1 Application is hereby made to San Joaquin County for a permit to construct and/oi install the work herein described. This <br /> i 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 <br /> rrServices. �/ <br /> ��5 !Yr �11�.L7 City LOD� --- 1,ot Size/Acreage t <br /> l Job Address - — <br /> IN&t N% RAN C 4 <br /> €' - 23 i1 0 <br /> Owner's Name - Address Phone <br /> ��x�,,110o ��i,�,c_[t a <br /> Contractors2taL. Address, r License No.JVT � Phone <br /> TYPE OF WELL/PUMP: :. NEW WELL ❑ L DESTRUCTION ❑ Out of Service Weil ❑ <br /> PUMP INSTALLATION ` SYSTEM REPAIR'❑ OTHER ❑ Monitoring Well C7 <br /> a � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE p <br /> ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D industrial ❑ Open Bottom L7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing t Specifications <br /> I"1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump I.VAG H.P. - State Work Done 7y✓�TA/l Z15C7" <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> W . <br /> it Depth �•".. <br /> Filler Material_& Depth. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I t Ili septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living.unitic Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity r No. Compartments <br /> w PKG. TREATMENT PLT. ❑ ' % . x Method of Disposal <br /> 1 Distance to nearest:L Well Foundation Property Line <br /> t <br /> j LEACHING LINE Cl No. & Length of lines = Total length/size <br /> FILTER BED ❑ Distance to nearest" Well # Foundation Property Line <br /> I — - <br /> SEEPAGE PITS 11 Depth Size -Number <br /> k SUMPS LI Distance to-nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS Q <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 /> M employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> ` cartifies the following: -11 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." p <br /> The applicant must call for all required inspec' ns. Complete drawing on rev rse sid t 1 <br /> f " 3�z, <br /> �, Signed J Title: Date: <br /> I f FOR DEPARTMENT USE.ONLY <br /> a Application Accepted by �� Date 1 2_ Area <br /> a <br /> Pit or Grout inspection by Date Final inspection by � �"L-+ <br /> 6 Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 4 <br /> i Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. E <br /> INFO CASH <br /> LA'S <br /> .i EH13-z1Stt[V.1/K51 <br /> � <br /> EH raze <br />