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Owners Name <br />TYPE OF WELL <br />0 Open Bottom <br />Cl Gravel Pack <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />OManteca Die. of Well Escevation Dia. of Well Casing <br />El. Tracy Type of Casing Specifications <br />Type of Pump H.P. State Work Oone <br />1-1 Other 1 -1 Delta Depth of Grout Sea! <br />Approx. Depth I I Eastern Surface Seal Insialled by <br />Well Diameter Sersling Materiel & Depth <br />Depth Filler Material ir Depth <br />Return STOO(Wft;' all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Box 2009, Stkn, CiS 952ol <br />APPLICATION <br />Application is <br />application la <br />Joaquin County <br />hereby ma4e,to San Joaquin County for a permit to construct an <br />made in compliance with San Joaquin County Ordinance No. 51+9 and 1 <br />Public Health Service's. <br />SAN JOAQUIN COUNTY PUBLIC REALT <br />ENVIRONMENTAL HEALTH DIVI <br />445 N SAN JOAQUIN, PHONE (209 10020 <br />P 0 BOX 2009, STOCKTON, CA 0 <br />PERMIT EXPIRES I YEAR FROM D bledika <br />77 <br />ate <br />7 firth (Complete in Triplicat <br />lee*/ ilartAdvi.- P-4 <br />1663_- Address <br />Job Address Lot Size/Acreage <br />Conlracaae,,...,--t_ AIA4..Aiddrestb iC; License Nf..11,3946 -1.-..- PhoneeaC7.2irie <br />TYPE OF WELL/PUMP • NEW WELL E WELL REPLACEMENT Hi DESTRUCTION LI Out of Service Weil 0 <br />PUMP INSTALLATION E?"------ SYSTEM REPAIR f!+------- OTHER C Monitoring Well cil <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />I hereby certify that I hive prepared Mip application arid that the work will be done in accordance with San Joaquin county ordinances. State laws, and <br />rules and regulations of the San Joaduin County <br />Home 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 in such manner as to become subject to workmen's compensation laws of California '' Contractors hiring or sub-contracting signature <br />certifies the following: "I certify that in ihe performance of the work for which this permit is issued, I shall employ parsons subject to workmen's compensa- <br />tion ewe of California." <br />The applicant mu all required ins ctions. Compete drawing on verse side. <br />Signed X Title: Date: ri:1-713 <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by <br />Pit or Grout Inspection by Date Final Inspection by <br />Additional Comments: <br />L Date <br />INFO <br />fk- <br />FEEAMOUNT DUE <br />_ <br />AMOUNT REMITTED - (4-5-1-) CASH RECEIVED BY DATE PERMIT .NO. <br />.----- <br />CO <br />,__,) .- <br />—) -66 f 6 2,3------'---41!)-n- 941M3 93 -It EH 13-24 04EV I/ 4s/ <br />EH 11-25 <br />Phone <br />&hi <br />Area 46 <br />Data ID -1C'33 <br />INTENDED USE <br />H ind •l <br />reirtomestic/Private <br />Public <br />I lirioation <br />Repair Work Done <br />Well Destruction <br />Type of Grout <br />TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR /ADDMON ' DESTRUCTION I I 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: Water table depth <br />SEPTIC TANK 0 Type/Mfg Capirity No. Compartments <br />PKG. TREATMENT PLT. Cl Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE El No. 8 Length of lines Total length/size <br />FILTER BED CI Distance to nearest: Well Founoation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Lin* <br />DISPOSAL PONDS 0