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r SAN . .+QUIN COUNTY PUBLIC HEALTH L .VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> Will, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for n permit to construct and/or install the work herein described. s <br /> application is made in compliance with San Joaquin County and the Rules and Regulations of San <br /> nty Ordinance No. 549 and 18 <br /> Joaquin County Public Health Services. <br /> Job Address ��"T' sT ,,/ <br /> e. E fM `(-+i,� City[I—�AJ045j Lot Size/Acreage <br /> 1�+` � ��,,•,� �^' <br /> Owner's Name <br /> Yl.�epli .*[�fr>L;S Address -Jr"""= I '1. 2g:2 Phgna 7 <br /> "fS-t5o , rIP�/h0 T �yf <br /> Address � License NNVPhone <br /> Conhaclor , r, <br /> WELL REPLACEMENT Cl DESTRUCTION Li of Service Well <br /> G 1 <br /> TYPE OF WELL/PUMP: NEW VJEIL ❑ OTHER G Monitoring Well <br /> � PUMP INSTALLATION �f SYSTEM REPAIR ❑ <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l <br /> Mae INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Specifications <br /> womeeic/Private ❑ Gravel Pack G Tracy Type of Casing— <br /> ['I Public 1-1Otherfl Delta Depth of Grout Seal <br /> I Irrigation _Approx. Oapthr�hl�Eastern Surface Seel Installed by <br /> Repair Work Done L3 Type of Pump ALL—CZ- H.P. Tf�� State Work Done <br /> Sealing Material i Depth42 AJ <br /> Well Destruction ❑ Well Diameter L <br /> Filler material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I availabett within 200 feetitsytem led it public sewer is <br /> Vali Installation will serve: Residence _ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: , <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> all LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> e. SEEPAGE PITS ti Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0t <br /> r 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 t <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 /> employ any person in such manner as to become subject to workman'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 /> law tion laws of California." <br /> The applicant Must call for all required inspectio Complete drawing on`rgyerse ids. / ^� <br /> Signed X <br /> �(" Title: —,/C/Q 1'. -�s.ic�-- Date: <br /> R ase EPARTMENY USE ONLY p <br /> hep,L�. Area <br /> Application Accepted by Q — Date A—_ <br /> rr Data Final Inspection by Data <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> is. Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Pcrmit/Services <br /> 445 N San Joaquin, P 0 Hoa 2009, Sekn, CA 95201 <br />