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SAN QUIN COUNTY PUBLIC HEALTHVICES <br /> ,.,MVIRONMENTAL HEALTH DIVZSR, ,'y <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 compliance with San Joaquin County Ordinance No. 549 and 2862 and the Rules zand.Regulations of San <br /> Joaquin County] Public Health Services. <br /> Job Address r 7 14, '�rsf� 8 w A-\ RA City LC4t Lot Size creage <br /> Owner's Namey INT_ Address lei t!+ u9I�t/J��/ _ Phone L)a --:A�M ; <br /> Contractor �rrgSs �,`C��9�K`.c1. Address Jr� act 67 �rr CA, Phone:.c� '�~'� <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well O <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 /> i <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [] Domestic/Private' ❑ Gravel Pack C1 Tracy Type of Casing_. Specifications <br /> I'I Public E7 Other 1­1 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 CJ Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth - <br /> TYPE Of SEPTIC WORK: NEW,INSTALLATION I I<F0PAIR! ITIO I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feat,) <br /> Installation will serve: Residence_ Commercial,.W., Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mig Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t" <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Lam. & Length of,Ines Total length/size X Q 1 <br /> FILTER BED n Distance to ne`are'st: Well Foundation {0 Property Line <br /> SEEPAGE PITS N(' <br /> Depth ; Size- s� X Number <br /> SUMPS LI Distance to nearest: Well /00 ' Foundation 161, <br /> Property tine � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and n <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's'Signature certifies the following: "I certify that in the performance of the worts 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 /> 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 Q required inspections. Complete drawing on reverse ,side. <br /> Signed !7'\— Title: {fir �`— _ Dais: <br /> FOR DEPARTMENT USE ONLY �7 <br /> Application Accepted by Date Z—4(— Area <br /> or Grout Inspection byate�' �33 Final Inspection by�as 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 0 Box 2009, Stkn, CA 55201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED lay GATE PERMIT NO. <br /> . EH 13-24(REV,i/n s) 0� AleC <br /> ke <br /> EH 14-M <br />