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SAN _ JUIN COUNTY PUBLIC HEALTH VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> /Joaquin County Public Health Services. <br /> x Job Address ,-3Z d Z C ' �" "��� 4v') A"o C, nix, Lot Size/Acreage �/ 4 <br /> )(Owner's Name X,4 C 16-IV / Address 'k /7/?, S'C Z� A' yL-. Phone <br /> Contractor ? _��W T Address �� .QoA 27 4' �Z License No. �95� 9 Phone_ �/0 / <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ S� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> T <br /> Ll Industrial U Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.1 Domestic/Private Cl Gravel Pack O Tracy Type of Casing_.. Specifications <br /> I'1 Public (1 Other n Delta Depth of Grout Seal Type of drout Py) <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material &-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) ' <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: s ; Water table depth / <br /> SEPTIC TANK O Type/M ap ci No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to near st. II un a io Property Line t <br /> LEACHING LINE L1 No. 6 Lenthholipes. Total length/size <br /> FILTER BED Cl Distance & NseingAqpmp e e Qr, nc pL <br /> Property Line <br /> -by ` u'ropm Al Health Big:d'n l <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 l: <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this p9rmit is issclbd, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiking 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 for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: ,weer 411,SO ' Date:FOR DEPARTMENT USE ONLY �} q <br /> Application Accepted by CY &1= Date t \ Area <br /> Pit or Grout Inspection by Date 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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> EM 13-24IREV,�iM5) �( Cl 3 /E-y� •oSG I <br /> EM N-2e <br />