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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 /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work berein described This <br /> application is made in cocpliance vith San Joaquin County Ordinance he 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address <br /> CityLot Site/Acreage <br /> C ' -AtO Camui <br /> Owner s Nan.- 4' Address &t ) Phone�`� <br /> Conttaudr ]t l� i Address �r.�: _License No Phon <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT CZ DESTRUCTION CT Out of Service Ii:11 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C1 � OTHER Monitoring <br /> �^well <br /> ' DISTANCE TO NEAREST SEPTIC TANK }si�-�_ SEWER LINES DISPOSAL FL _T-0-Ed PROP LINE} T� <br /> FOUNDATION >ICC a- AGRICULTURE WELL>,�,- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO SPECIFPCATIONS ff <br /> M Industrial 0 Open Bottom 0 Manteca ' Dia of Well f cavation Dia JGen Weil <br /> ^8 , <br /> ' n Domestic/Private RrGravel P ck Tracy Tym- I Ca ng �' Specific Ong j <br /> I l Public n, Other F1 Delta Depth of \out Sea ype <br /> I I IrriOatran pro: Depth 1 1 Eastern Surface SauNnstafI d b / <br /> Repair Work Done LD T of Pump H P State WorK Done \ <br /> Well Destruction 0 'Well Oiameteh it Scaling Material. i Depth <br /> Depth Filler Material k Depth <br /> PE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted tl public sewer is <br /> available within 200 lest 1 <br /> Installation will serve Residence — Commercial _„_ Other <br /> Number of Irving units Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT 0 Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> J SUMPS Ll Distance to nearest Well Foundation Property Line <br /> s <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances stale 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 /> emplay any person to such manner as to become sublect to workman s compensation laws of California Contractors hiring or sub-contracting signature <br /> certifies the following 1 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 applics ust call lot all cared inspections Complete drawing on reverse side <br /> Signed 7 Title a _--_ Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> LC,tar".�� Date �t' 1<� Area <br /> t or Grout Inspection by I Date 1t1r �n Z- Final Inspection by ti+ Date <br /> j Additional Comments r14'-' a-tr2 t )a.. z ! <br /> Applicant - !return all copies to San Joaquq County Pu is Health Services <br /> Environmental Health Permit/Services ri, <br /> 445 N San Joaquin. P O Box 2009. Stkn. CA 95201 K -air-i r i_ J 0 x'11 i <br /> FEE AMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT NO <br /> INFO CA5H <br /> � w► !J <br /> EK 13.24 PIEv I In si r� �4r f"7G S� I 14Th <br /> FN 1A 20 <br />