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I <br /> SAN JUIN COUNTY PUBLIC HEALTH SICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgP <br /> IRES 1 YEAR FROM DATE ISSUED COPY <br /> (Complete in Triplicate) <br /> Application is hereby made � 8Ban nce vithu$anCJoaqulnfor <br /> Countypermit <br /> OrdinancenNoru5k9and/or <br /> 1862install <br /> and thethe <br /> Rules and Regulationsdescribed. <br /> of SanThis <br /> application is mad <br /> Joaquin county Public Health Services. <br /> City k, 4—deIIi-I Lot size/Acreage <br /> Job Address <br /> Phone <br /> s <br /> Owner's Name <br /> License No.q�Phone <br /> Address 57RUC710N ❑ Aut of Service Weil ❑ <br /> ContractorDE <br /> WELL_ REPLACEMENT C7 Monitoring Well ❑ <br /> TYPE OF <br /> —Z NEW NEW WELL ❑ SYSTEM REPAIR ❑ OTHER <br /> PUMP INSTALLATION <br /> SEWER LINES _ — D15POSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �— PkTSISUMPS r..� <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL qq <br /> INTENDED USETYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing h' <br /> C.} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications— <br /> + <br /> C:l pomesuc/Private ❑ Gravel Pack ❑ Tracy DeptType of Casing_h of Grout Seal Type of Grout <br /> I'1 Public 1-1 Other f l Delta <br /> I I Irrigation —Approx. Depth I i Eastern Surface Seuk Installed by <br /> of Pump K.P. Stats Work one —t 11 C1 �� <br /> Repair Work Done U Type 4 Sealing Material i Depth atwimir 117115 <br /> Well Destruction Well Diameter -ib-!_ �*,� ® .� 70 T - <br /> Depth Lam=—� Filler Materiel 3 Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLAc system <br /> TION t 1 REPAISIADDITION I 1 DESTRUCTION l I alvaikabPelwihin 200 feetperm.) if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Ns s <br /> SEPTIC TANK ❑ Type/Mfg Capacity 7 <br /> Method of Disposal <br /> I PKG. TREATMENT PLT. Cl Property Lina <br /> I Distance to nearest: Well Foun �--- <br /> Total length/size <br /> LEACHING LINE Ll No. & Length of lines Property Line <br /> k FILTER BED C] Distance to nearest: ell Foundation <br /> r <br /> Sire Number <br /> SEEPAGE PITS 11 Depth <br /> Well. Foundation Property Line <br /> SUMPS Cl ante to nearest: <br /> DISPOSAL PONDS <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby certify that I have prepared this application and <br /> rules and regulations of the San Joaquin County <br /> Homs 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;n such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 1 certifies the tolls 'ng: u certify that s the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cel' r <br /> The applicant or all nspections. Complete drawing on revers side. f <br /> Signed Title: <br /> 401 le:11 <br /> Date: / <br /> 11,01 FOR DEPARTMENT USE ONLY {�! <br /> Date <br /> Applicrea <br /> ation Accepted by -y <br /> Pit or Grout Inspection by Date <br /> Final inspection by Date <br /> At <br /> t Additional Comments, 'y <br /> Applicant - Return 'all copies to: San Joaquin County Public Health Services '1 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201"" r <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> I INFO <br /> EH 13.24 414 EV.1 M 51 y <br /> `` EH 14.26 <br />