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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I€ ENVIRONMENTAL HEALTH DIVISION <br /> f. 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> IR <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ! <br /> i <br /> Application Se hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in conT;iance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin C6unty Public Health Services. <br /> IOU)Job Address .c . 1� � -- City Lot Size/Acreage <br /> w is a' e &"ZtaA dr Phone <br /> ii • <br /> o f r r' M s i e No. Phone <br /> qs— <br /> TYPE OF WELL/PUMP: I i� NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> V Monitoring Well <br /> ! PUMPI INSTALLATIO SYS7EM'REP SIR C7 OTHER ❑ C] <br /> DISTANCEl�TO NEAREST: SEPTIC TANK SEWER LINES -�� �_ DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL 1� l OTHER WELL PITS/SUMPS \ ,' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> AL1 II osteal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> y4.GZorraestii/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'I Public is Other f1 Delta Depth of Grout Seai Type of Grout <br /> 1 1 Irrigation .Approx. Dept I Eastefn^� Surface Saul Installed by <br /> Repair Work Done 0 Type of Pu H:P:- — State Work D <br /> Well Destruction ❑ 'Well 8iameter SSealing Material b Depth <br /> .t <br /> DepthFiller Material 3 Depth <br /> TYPE OF SEPTIC WORK; NEW-INSTALLAT40N:I;I-.-RE,RAIR/ADDITION I I DESTRUCTION I I INo septic system permitt!i1pUbliC <br /> available within 200 feet.) <br /> installation will serve: Residence_ Commercial T Other <br /> Number of living units: Number of bedrooms' <br /> E Character of soil to a depth'of 3 feet: Water table depth <br /> SEPTIC TANK 13 iTy eiMfg i Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ I� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br />� IM , <br /> 4 <br /> LEACHING:LINE ❑ 'No-& Length of lines Total length/size <br /> FILTER BED ❑ ,Distance_to_nearest:y W lel;+`1 Foundation Property Line <br /> SEEPAGE PITS II Depth f Size Number <br /> SUMPS LI Distance to nearest: Well r Foundation Property Line <br /> DISPOSAL.'PONDS ❑ <br /> I hereby certify that I have prepaied 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 iJga_q_w 0_County, q <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 /> employ any person in such manner as to become subject to workmen'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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant s call f IF ins tions, Complete drawin an reVide. <br /> r y <br /> Sign d Title: Date: <br /> ik. <br /> i+ FOR DEPARTMENT USE ONLY <br /> 2l <br /> Applicationi;)Accepted by _ Data A►ea f <br /> Pit or Grout Inspection by 'i Date Final Inspection by <br /> Date L <br /> Additional Comments: I� <br /> ii. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO DUE AMOUNT REMITTED K <br /> RECEIVED BY DATEPERMIT'NO. <br /> AMOUfJiTI <br /> em 3EHi{2�4e1REY.rixs� �� � .� <br />