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Si _ - — --'--- -- - - - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESS- <br /> N I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> r P 0 BOX 2009, STOCKTON, CA 95201 N t Wjc�ru-� <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SttniJoaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in compliance�lrith San Joaquin County Ordinance No. 549 and 1862 and the Rules- and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address2Z i:5 ZC+ r1 City C� Lot Size/A gage <br /> I (&1 t.{,1.I—____•--- r� ddress (D1 0 S. Wet-1 Ke-r- "Phone <br /> 1 <br /> Owner's Name ,�C.t-tr>r1 v r?��14 <br /> Contractor--se - Address . <br /> - - License Na. 4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION)( Out of Service well ❑ <br /> PUMP INSTAL-L-ATION-O - SY.ST.EM-REPAIRd-C-7 OTHER ElMonitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> Fl Public CI Other. l ]-1 Delta Depth of Grout Seat Type of Grout <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 ❑ Wall Diameter; Sealing Material &Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION' (No septic system permitted if public sewer is <br /> lCornmercial <br /> available within 200 feet.I <br /> Installation will serve: Residence _ Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feat: Water table depth I <br /> SEPTIC TANK ❑ Type/Mfg `. Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. ❑ � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wet] Foundation Property Line t <br /> I <br /> SEEPAGE PITS 11 Depth Size Number ` <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 i <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the perlormarrceJ6f'the work 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, t shall employ persons subject to compensa" <br /> tion lays of California." I , o workman's l <br /> The apptican st call for all req ins!ctions Complete drawing on reverse side. I. <br /> Signe X <br /> t <br /> Title: Lr�r/1�e` •-- Date., <br /> FOR <br /> � ° t <br /> j FOR DEPARTMENT USE ONLY �i <br /> Application Accepted byA ) '� -- Date 3— 1 ^[Z-- ea cA <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: -3 Cyit!Ll + <br /> r <br /> Applicant - Return all copies4,-to;-8an-J6aquin"Countq•-Pub3•ic^'Heal't`ti Ser'vice��s"""-- <br /> Environmental Health Permit/Services <br /> - 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE EFF AMOUNT REMITTED RECEIVED BY PATE PERM17'NO. <br /> INFO /� ry, 1115 <br /> /CWS H ry g <br /> j EH 14.E(REV.i i N SY r i.d /' O 16151 ��/f .2 .6�/�S <br />