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1 <br /> ..:� SAN JOAQUIN COUNTY PUBLIC HEALTH SkAVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 J <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 herein described. This <br /> application to made In compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address d' I ee G' Cr 6.C14-eZe_¢' t_, ..-� w� City L(_(& Loi. Size/Acreage r 1f <br /> Owner's Namet_, r '�ItAddress <br /> 1V � I <br /> t s JJ <br /> Contractor 1� tci c �.{• 4^ .I�{�c Address P'l 6,t <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT: <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial C7 Open Bottom Cl Manteca pia. of Well Excavation Dia. of Well Casing <br /> f.l Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing-.--- Specifications <br /> I'I Public (-1 Other FI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Appfox. Depth I I Eastern Surface Setif Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material & Depth `JJ <br /> Depth Filler Material & Depth . <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION (No septic system permitted if public sewer is l <br /> available within 200 feet.) C 1 <br /> Installation will serve: Residence— Commercial_ Other r t. <br /> Number of living units: Number of bedrooms <br /> Character of Boit to a depth of 3 feet: Water table depth. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 <br /> PKG, TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> _ <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI 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 171j <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, 1 shell n <br /> employ any person in such planner as to become subject to workman's compensation taws 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California.'! <br /> The applicant must call for all requited <br /> �e inspa:lions. Complete drawing on reverse side. <br /> eG <br />+ Signed X L ) AAA vlf { Title: —�__a_L) — Date: I r 1 .- I� . ,- ^) <br /> FOR DEPARTMENT USE ONLY <br /> v - - / J <br /> Application Accepted by-- �1 Date_(a= 2 ,Area <br /> Pit or Grout Inspection by a Final Inspection by Date � L <br /> Additional Comments: <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 /> JYFEEAMOUNT DUE AMOUNT REMITTED CASRECEIVED BY DATE PERMITNOEH 17.2.rpt v.l �-v 4 d <br /> EH 14 2e <br />