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SAN �' QUIN COUNTY PUBLIC HEALTH ' VICES <br /> a'NV r 11ONMENTAL HEALTH D I V I S I�_. ' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED �®FIV <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 is made in'convilaAce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> XJob Address ' <br /> City A4 Gat Size/Acreage <br /> s <br /> ! l Owner's Name "Al Address • . <br /> - -- Phone <br /> ,0�41 <br /> ,onhactor �//� ' <br /> Address license No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of ServiceKrell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well U <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial , ❑ Open Bottom © Manteca pia. of Welt Eucavation <br /> Cl Domestic/Private 0 Gravel Pack 0 Trac T Dia• of Well Casing <br /> Tracy Type of Cdsing_ Specifications <br /> ('1 Public Cl Other' Cl Delta Depth of Grout Seal �^ <br /> Type of Grout <br /> i I t lrriRation `Approx. Depth I I Eastern Surface Seel Installed by <br /> Repair Work bone U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material i Depth J <br /> Depth_ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I ^REPAIRIADDITION I I DESTRUCTION'ti INo septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of IMng units: Number of bedrooms <br /> Character of soil to s depth of 3 feats <br /> ;:. SEPTIC TANK. <br /> . .._._ Water table depth <br /> _._ 0 _:Type/Mfg � -Capacity--�-�� -.-No.-Compartments <br /> PKG. TREATMENT PLT. Cl -- — <br /> Method of Disposal <br /> Distance to nearest: <br /> Will Foundation Property Line - s <br /> LEACHING LINE ❑ No. ✓E Length of lines <br /> Total leng(h/size Y' <br /> FILTER BED ❑ Distance to nearest: Well Foundation�_ /1 <br /> ..� Properly Line e+r <br /> SEEPAGE PITS 11 Depth Size <br /> 'SUMPS Number <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ `— -- PtQp°i1Y Line <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Jo <br /> rules and re uliitions of h Joaquin county g the San Joaquin Count 4 ordinances, state laws and <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to become subject to workman's certify that in the performance of the work for which this permit is issued, I shall not <br /> of certifies the following: 'I certify that in the performance of the work fol whicl~h this tion Vis issued, I shall employ ractor's hiring or sub-contracting signature <br /> Non laws of California." persona subject to workman's compansa• <br /> f�The applicant must call for all required inspecftions. Complete drawing on reverse side. <br /> Signed <br /> ff �� Title: Date: <br /> ` DEPAgTMENT USE ONLY <br /> Application Accepted by ,- .,, �_,� Data L <br /> as <br /> Pit or Grout Inspection by <br /> Data Final Inspection b <br /> r Date _'2__ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin comity public Health Services <br /> �I Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FETE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> \€H 1771 fPfV.wim SI <br /> 'fir 20 ., � <br />