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�vr.1.. <br /> w� <br /> ii <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 L+ <br /> { Y (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:County0xd1nance-So.-549mand_1$62,•and_the_Rules-and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address � / /y r�l� A�/dK 1�� /�/� City Lot Size/Acreage �f(p <br /> Owner's Name f? /!Address 1,4,182 CI� oni__/ <br /> Contractor 5 Address �212e!2 XV)4 5;/ License No: Phone <br /> } TYPE OF WELL/PUMP:' NEW WELLX WELL REPLACEMENT ❑ DESTR'bCTION O''Out of Service Well ❑ <br /> PUMP INSTALLATION y SYSTEMSAEPAIR ❑ '� OTHEPi ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL hD. « ROP. LINE <br /> t FOUNDATION __[�� AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTIOrN�,SPECiFICATION <br /> f7 Indust�ria I ❑ Open Bottom ❑ Manteca .Dia. of Well Excavation Dia. of Well Casing <br /> 1 <br /> Domestic/Private ;Gravel Pack tw"--Ll Tracy Type of Casing_ Specifications--- =1-.1�� <br /> I'] Public *-�i,-�1 RW "'Soul <br /> pelta Depth of Grout Seal _ j Type lof Gout f1_ <br /> I i Irrigation. C Approx. Depth I I Eastern Surface�5eal Installed by . ' S ,�L'd� �f 7 <br /> Repair Work Done U Type of Pump H.P. �" �. Mate Work Done_ <br /> tf Well Destruction ❑ Well Diameter Sealing Material & Depth , <br /> } s Depth Filter Material & Depth <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION l I REPAIRIADOITION I i DESTRUCTION I I lNo septic system peimittad if public sewer is <br /> i available within 206-feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number-of living units: -`_'�Number of bedrooms <br /> F <br /> Character of'soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK ❑�Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Gl <br /> I Method of4Disposal <br /> Distance to nearest: Well Foundation - Property Line <br /> LEACHING LINE Cl No. & Length of lines, Total'length/size <br /> FILTER BED ❑ Distance to nearest: r Well Foundation ' <br /> :Property Line <br /> l •.tip h \ f_ <br /> SEEPAGE PITS 11 Depth Size 4 ; Number <br /> SUMPS Ll Distance to nearest: i`Well Foundation Property Line y <br /> DISPOSAL PONDS ❑ { ' l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin criuniy ordinances, state laws, and <br /> rules and regulations of the San Joaquin County ! { !!! <br /> Home owner or licensed agent's signature certifies the folli ` <br /> 8 9 g: "Pcertity that in the performance.of the workfSr which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to work man'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 persona subject to workman's compensa- <br /> tion laws of Calitor „ <br /> [ t <br /> The applicant Ir requir In . Complete drawing on reveside. <br /> ~. <br /> Signed i Date: 3 �, <br /> f FO DEPARTMENT USE-ONLY ' <br /> Application Accepted by �Date F `I`--i2 Area <br /> Pit or&Inspection by „L Date 5/z"XrzFinaI Inspection by, �r 9 Date C C 'ut, } <br /> Additional Comments: `�� f- r�" art -- frduj <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 9520.1 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> Eli 13.21(REY,I/n 5? wN � A 9e) <br /> ,2 <br /> EM 114e - <br /> j !J <br />