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SAN J }JUIN COUNTY PUBLIC HEALTH S.- "ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> .K <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr" + <br /> (Complete in Triplicate) <br /> F1 Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in conpliance with San Joaquin County Ordinance no. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> -Pt <br /> F Job Address City Lot Size/Acreage <br /> r <br /> Owner's Name �—,E T -_:)fA.,JeEZfa+, Address / Phone <br /> Contractor A Zz��(J� G+1 Address lip�� ��( _ /YAC icense Nt,�_A:i�- s -Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I"1 DESTRUCTION Cl Out of Service Well L❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE <br /> F E <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 n industrial ❑ Open Bottom ❑ Manteca 'Pia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'I Public C7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I i Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth +� <br /> Depth Filler Material ti Depth Ll <br /> III TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted it public sewer is <br /> Favailable within 200leet.l. ..._. .. <br /> Installation will serve: Residence Commercial— Other <br /> { Number of living units: / Number of bedroomsR <br /> T <br /> 1 1Character f soil to a depth of 3 feet: Water table depthth <br /> SEPTIC TANK. ❑ Type/Mfg Ca acitY No. Compartments <br /> (� <br /> F <br /> PKG. TREATMENT PLT,Q Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> (� LEACHING LINE No. & Length of lines Total length/size' <br /> tib <br /> t FILTER BED CI Distance to nearest. Well Foundation Property Line <br /> t SEEPAGE PITS 11 Depth —Size. /p Y 1-07 _ Number <br /> SUMPS Distance to nearest: Well T Foundation Property Line <br /> t 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 <br /> F1 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 /> cartifiss 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 for all re fired ins ctions. Complete drawing on reverse side. <br /> _. <br /> Signed X Title: Date: <br />` FOR DEPARTMENT USE ONLY +� <br /> Fi Application Accepted by Dat o qZ, Area _ �{ <br /> Pit or Grout Inspection by Date Final Inspection by Date 2�7 <br /> FiAdditional Comments: <br /> Applicant - Return all copies to: Sap Joaquin County.Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San •Joaggin; 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> Fo <br /> EH 13-241REV.r/R5)EM 14.26 <br />