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f <br /> T i SAID G+QA UIN COUNTY PUBLIC <br /> � Ic gEAL�a SE�v�€�s_ <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> 445 N SARI iOAQUIN, PRONE (209)468— IA <br /> �� �• <br /> P 0 BOX 2009, STOCKTON, CA 9520: � <br /> PERMIT EXPIRES I YEAR FROM DATEfISSUED <br /> F <br /> (Complete in Triplicate)` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein describe s <br /> application is spade in compliance with San Joaquin County Ordinance No. 5i9 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r �- <br /> Job Address City Lot Size/Acreage <br /> � I <br /> Name Address <br /> Owner's ���- �� Phone <br /> Contractor Address P icense NoPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ . <br /> PUMP INSTAL LATkON C7 SYSTEM AFFAIR ❑ OTHER [] Monitoring Well ❑ <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PP08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �' Qf Wel! Casing <br /> UI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of"Casing ;M� <br /> s <br /> CI Public Fl Other' f-1 Delta Depth 64 Grout Seal out <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed b <br /> y <br /> SAAf <br /> Repair Work Done GJ Type of Pump H.P. <br /> Well Destruction C] Well Diameter Sealing Material & Depth �DI�� <br /> Depth Filler Material a} Depth 4 E ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR%ADDITION X DESTRUCTION I 1 1No septic system pe ,public sewer is <br /> available within 200 feet.l U`t <br /> Installation will serve: Residence <br /> Commercial— Other <br /> Number of living units: Number of bedrooms. ^. , <br /> Character of soil to"a depth of 3 feet: V Water table depth \ i <br /> SEPTIC TANK ❑ T /Mf <br /> YPe 9 4 Cvapacity No. Compartments <br /> PKG. TREATMENT PLT, til Method of Disposal <br /> r <br /> Distance to nearest: Well T Foundation' I <br /> Property ;n { <br /> P yL e . _ <br /> LEACHING LINE <br /> i i ( No. & Length of lines _ Total length/size s <br /> FILTER BED ❑ Distance to nearest; WaU � Foundation Property Line <br /> SEEPAGE PITS f 1 Depth �(��� Size -0 Number l <br /> F - - <br /> I <br /> SUMPS X Distance to nearest: welly Foundation -Property Line 4&2 <br /> � <br /> DISPOSAL PONDS ❑ <br /> FI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, andrules and regulations of the San Joaquin county <br /> Home owner or licensed agent's aignature.cenifies 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 must call far II required inspections. Complete drawing on reverse side. <br /> Signed 7idec: erg <Dat <br /> e: -- <br /> FOR DEPARTMENT USE ONLY <br /> .Application Accepted by Date Z Q Area <br /> F1 <br /> , Pit or Grout Inspection by Dat <br /> Final Inspection by Date <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 /> INFO AMOUNT DUE AMOUNT.REMlTTEO C H CEIVED.BY DATE PERMIT'NO. <br /> i EH 13-24-IREV.r i n 5114, <br /> EH 14.29 - ! r <br />