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s� <br /> 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 /> P_ <br /> Application is hereby made to San Joaquin County fora 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 /> f`q t/Q <br /> Job Address L[r �9 Cit �Q�f l Lot Size/Acreage <br /> Y <br /> Owner's Name 1 �� ��� ' ' ' Address Phone <br /> !c ontractor s License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of service Well ❑ <br /> -, +t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> } FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> lfVTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial,"ti ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:} Domestic/Pldvate ❑ Gravel Pack7 El.Tray Type of Casing_. Specifications <br /> Il Public 1-1 Other C1 Delta Depth of Grout Seal `� Type of Grout <br /> I IIrrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done � I <br /> Well Destruction CSWell Diameter Sealing Material & Depth <br /> \Depth Filler Material & Depth <br /> 1 <br /> TYPE OF SEPTIC WORK: ''NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I !No septic system permitted if public sewer is <br /> r 11 i available within 200 feet.) <br /> Installation will serve: Resiids ce• Commercial Other <br /> Number of living units: _Lm_, Number of bedrooms -- , <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. ❑ Method of Disposal <br /> Distance to,nearest: Well Foundation Property Line ? <br /> LEACHING LINE CI No. & Length of lines _ � Total length/size <br />~' FILTER BED 0 Distance to nearest: Well /4 Foundation A2 f Property Line /4� <br /> iSEEPAGE PITS l I Depth , Number 7✓ <br /> rf SUMPS I_I Distance to nearest: Well ./ - 1+ Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 _ ��'• <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 1 t \ <br /> Home owner or licensed agent's signature certifies tfie following: "I certify that in the performance of the work for which this permit is issued, I shall not <br />'s employ any person in such rnanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 3 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compens 11 <br /> tion laws of California." <br /> r ! ! <br /> r <br /> The applic A)s't for all re vire inspe.c 'ons.l Compl$te drawing on reverse side. <br /> Signed ~ �_ <br /> '- f Title: 4A!, _` Date: Z� L �y <br /> PARTMENT USE ONLY\s }o <br /> Application Accepted by Date �� Area <br /> Rit or Grout Inspection by ate; Fina'11nspectlon_b d• ' `4� r <br /> Additional Comments: w, <br /> ` _ ,Y•a::.y,* <br /> Applicant - Return all copies to: 'San Joaquin County,'.Piit;11e Healtki Services <br /> Environmental Health%Permit/Serwices a 'j <br /> 445-N San Joaquin, P 0 Box 2009; Stkh,CA'95�OY <br /> - E k <br /> FEE <br /> E -AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DQE„ PERMIT'NO.INFO ( Ir <br /> tH1 <br /> 3.24 IREV.11in51 Sart // y O� <br /> EH 11428 !!! ��WYY CCV JJ d is <br /> v <br />