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"PL1(.A110N rUtt PERM11 <br /> iSAN JbAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 fi_ HAZELTON AVE. , PHONE (249)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> P&P 3� EXPIRES 1 YEAR FRQM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicrttion is hereby made to San Joaquin County for a permit to construct and/or install the work herein described This <br /> Rrplication Is onde in compliance with San Joaquin County Ordinance No 51+9 and 1862 and the Rules and Regulations of Saq <br /> I-Rqutri County Public Health Services <br /> 1 <br /> 1nb Address City Zk ,k/Vi..fot Size/Acreage17Y yz <br /> , <br /> Owner s Name Address Phone <br /> A n 17", Zkg/ <br /> ronlra[tor ss cense No ones/[J�_ <br /> TYPE OF WELL/PUMP WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well L"1 <br />' 4PUMP INSTALLATIO/N��0 SYSTEM REPAIR ❑ OTHER 173J Monitoring Well ' <br /> DISTANCE TO NEAREST SEPTIC TANK 158.E SEWER LINES DISPOSAL FLD -AA:7 PROP LINE <br /> y FOUNDATION 430 -" AGRICULTURE WELL? OTHER WELL..,CLLCL,IC.0 PITS/SUMPS A4q <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S. <br /> I 1 Industrial �, ❑ Open Bottom ❑ Manteca Drs of Well Excava o D1a of Well Casing <br /> I I Domestic/Private Gravel Pack I-) Tracy Type of Casing Specifics j <br /> r I PIFbIrc 1 T Other XCelta Depth of Grout Sea! 1W Type of row r ImP4 10L it <br /> + I In,tlauon d rl Approx Depth 1 1 Eastern Surface Seat Installed by <br /> Rwnair Work Done 0 Type of Pump H P State Work Done _ <br /> Wpft Destruction Q Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted of public sewer is <br /> available within 200 feet I <br /> Installation will serve Residence — Commercial _ Other <br /> Number of living units - Number of bedrooms _ <br /> ('haracter of &oil to a depth of 3 feet Water table depth <br /> lzfPTIC TANK [_I Type/Mfg Capacity No Compartments <br />' PKG TREATMENT PLT U Method of Disposal <br /> Distance to nearest Well _ Foundation Property Line <br /> LEACHING LINE Cl No & Length of lines Total length/size <br />' FILTER BED I ) Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS It Distance to nearest Well Foundation Piopeny Line <br /> DISPOSAL PONDS L7 <br /> l hereby certify that 1 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 signalure caniftes the following 1 certify that in the performance of the work for which this permit 1s 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 br sub contracting signature <br /> cert+fres 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 coriipensa <br /> tion laws of California" <br /> The applicant ust call for all required Inspections Complete drawing on reverse side <br /> Signed X-I&LU Titlea �� — Date <br /> FOR bEPAf{T EMT USE ONLY 3�j <br /> Application Accepted by Date Area 11! �` <br /> ril or Grout Inspection by _ at Final Inspection by DateZ� <br /> 'Idmonal Comments /� S <br /> rpllcnnt - Return all copies to Sen Jonqui County Public Healtv <br /> Services, Frivironment^1 Health Permit/Services i <br /> ]601 E Hazelton Ave , P O Sox 2009, Stockton, CA 95241 <br /> f F AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE If PERMIT NO <br /> INFO CASH <br /> r1 <br /> 2•ir+ry + s, <br /> 1 N til �� � 11002- 08 <br />