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r <br /> • ' 3ySAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> = .t j445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> opy <br /> 2FMIT OH DATE ISSUND <br /> (Complete in Triplicate) l <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described. This <br /> application !e made is compliance with flan Joaquin County Ordinance No. 549 and 1e62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> jr Ig Jab Address Ci Lot Size/acreage <br /> 3(ot--wo ,w <br /> Owner's NAddress Phone q i <br /> a.. s- ; <br /> Address b r License No. Phone <br /> Contrac -- <br /> TYPE-OF WELLIPUMP'. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> '- .,PUMP INSTALLATI0N;I7' SYSTEM AEPAIR ❑ OTHER ❑ Monitdring Well L1 <br /> DISTANCE.TO NEAFtE�T,SEP,TIC�TANK SEWER LINES DISPOSAL FLO. PROP- LINE <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITSJSUMPS - <br /> " '"�1NT IiIDEO�l75E' TYPE-OF-WELL -PROBLEM AREA--CONSTRUCTION SPECIFiCATIONS1 <br /> ❑ Industrial ❑ Open Bottom 151 Manteca Dia-of well Excavation -Dia...of Well Casing F.T <br /> 1.1 Domestic! rivate Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public." 1-1 Other I 1 Delta Depth of Grout Seal Type o1 Grout <br /> I i Irrigation" —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Gone D Type of Pump ' H.P. State Work Dona <br /> Well Destruction O Well Dismeter /' Sealing Material i Depth <br /> / Filler eriak i Depth <br /> Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAIR! DOITIO DESTRUCTION I I INo septic system permitted if pubkc sewer is 1 <br /> available within 200 feet.) <br /> Installation will carve: �_ Commercial Other,��_ a�.��E .�, r�� <br /> I <br /> Number of living units: Number ooms o4��,�� ��� ` ,6 � `'lJ <br /> Character of soil to a depth of 3 feat: �t Water,table depth 'f <br /> SEPTIC TANK ❑ Typo/Mfg Capacity_3a6©O No. Compartments <br /> :v <br /> PKG. TREATMENT PLT,Q d Method of Disposal <br /> Distance to nearest:, Well Foundation Property tine <br /> I <br /> TEACHING LINENo. A Length.of-Vries ' — Oma+ -- --- Tptai length/size 400 19 <br /> 145 <br /> FILTER BED 0 Distance to nearest:- WWI sjo Foundation I Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Cl Distance to neared: Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> "Ie9Fiy Cents,#It I-K1%Wgo- arsd ltirs applieatian and that the worx'Viiill ce`w <br /> tis done in accnrdanith Sen Joaquin county ordinances.-stats Taws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies tAs following: "I certify that in the parlormance of the work for which this permit is issued,I shall not <br /> employ any person in such manner as to become subject to workmen's compensation law$of California." Contractor's hiring of 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 workmen's eompensa- <br /> Wn laws of California." <br /> The applicant t cap for U4 inspections. Ca plate drawing on reverse aide <br /> qD <br /> Signed X <br /> Tide <br /> FOR DEPARTMENT USE ONLY 7 p <br /> Application Accepted by ` Date - Z'r-'f-=[-L - Area �' 2 <br /> E�or Grout fnapection by Date Final Inspaction by�+C.9 <br /> Additional Comments; ' <br /> Applicant - Return all copies to: San Joaqulu•,County Public liealth'Services { <br /> Soviroamental Health Permit/Services <br /> 445 N flan Joaquin, P 0 Sox 2009, Mn. CA 05201 <br /> FEE AMOUNT DUE AMOUNT REMITTED JJ= RECEIVED BY DATE PERM17'NO. <br /> INFO ! <br /> EX 111-25 �+ �/ <br />