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°f <br /> II 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 /> II 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 vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ServiceB. <br /> Job Address O SA City Swot/V Lot Size/Acreage <br /> fin[ <br /> LC�'i n � :s <br /> Owner's Name ` � �ddress w �/"'�'+�-' G 1 —_—'`Phone �� 16 <br /> Contractor I <br /> Address �Ple s ` y <br /> 43 Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION` SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> ! DISTANCE TO NEAREST: SEPTIC TANK f" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L� Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> i'1 Public 1-1 Other ,I 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.._'Approx. Depth l I Eastern Surface tSeedi Installed by JQ <br /> Repair Work Done 0 Type Pump; H.P. QL /�[InState Work Dona <br /> Well Destruction ❑ Well Diameter I' Sealing Material to Depth 0 Ad <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ! I DESTRUCTION { I lNo septic system permitted if public sewer is <br /> F g available within 200 feet.) <br /> N <br /> Installation will serve: Residence Commercial_ Other <br /> t Number of living units: 'I Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ir Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 11 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total iength/size <br /> FILTER BED ❑r.Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depifi Size Number <br /> J <br /> SUMPS Cl.. Distance to_.,nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 aignature 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-laws of California:" Contractor'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 ahali employ persons subject-to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required in tions. plate drawing on r ver sid <br /> ib ¢ 9 <br /> Signed Tide: ._ Oats: <br /> R �9 DEPARTMENT USE ONLY <br /> Application Accepted by O+�w� Date r- Area <br /> Pit or Grout Inspection by Date Final Inspection b Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> l Environmental Health Permit/Services <br /> n q 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CAK 11 <br /> SH RECEIVED BY DATE PERMIT'NO. <br /> • EH i3•?4{AEY.r/n 51 T K O " a !� Y7 fl 7 <br /> i EH 74.26 �\ v <br />