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SAN AQIJIN-COIINTY PIIHLIC HEALTH QRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN' JOAQUIN, PHONE (209)468-3420 j <br /> P 0'BO% 2009, STOCKTON, CA 9520 . <br /> PERMIF E7lPIRES' 1 YEAR FROM DATE ISSIIED <br /> (Complete in Triplicate) , <br /> l ; t <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 its compliance vith Sas Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Josquin County Public Health Services. <br /> 0��: C� 4� <,t �" L-.J(ti♦ City L10Lot Size/Acreage 'If J C,r- <br /> S <br /> Job Address _ �4 <br /> y� Address y �` .Phone 36 <br /> Owner's Name cf f <br /> (441 C e e V,.L;^tri <br /> Contractor f� ' Address36l GnY �e' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELT. REPLACEMENT C] DESTRUCTION Ll Out of Service well ❑ <br /> + SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ::; / . <br /> P. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. — PROP. LINE <br /> 'r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> •C• <br /> O Industria+ ❑ Open Bottom a Manteca Dia. of Well Excavation �g� <br /> [! Domestic/Private ! 40 <br /> PGravel Pack !❑Tracy Type of Casing Specifications.` <br /> l'1 Public s ' a± n Other il: Delta Depth of Grout 5eai '�' _ Type of Grout <br /> 1 <br /> I i Irrigation i Approx. Depth + I Eastern Surface Soul installed by ` <br /> Repair Work Done U .;, Type of Pump <br /> fV H.P. State Work Done <br /> Sealing Material & Depth SL'�`t ± a� <br /> Well Destruction ❑ Well Diameter <br /> Depth nMA <br /> . _( / Filler Material-& Depth J� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADOITION 1 1 -.DESTRUCTION I I (No septic system permitted it public server is h <br /> available within 2W feet.l <br /> Installation will serve: Residence— Comrriercisi` 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 �❑ Type/Mfg Capacity No. Compartments <br /> F Method of Disposal <br /> PKG. TREATMENT PLT.'O , <br /> Distance to nearest Weil Foundation Property Line t <br /> LEACHING LINE I . <br /> ❑ No & Length of limes. Total length/size j <br /> : g <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS "I I Depth Size Number <br /> SUMPS L3 Distance to nearest Weil Foundation Proprty in ? <br /> DISPOSAL PONDS .1❑ <br /> I hereby certify that I have prepared this applicanon and.that the work will be done in accordance F4Wou 1044W&Aces, state laws, and .1 <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 4 �10"ch� ermit is issued, I shall riot <br /> employ any person in such manner as to become subject to workman's compensation laws of California.",Contractor's +,iSSlnQ,,r ub ntracting signature <br /> certifies the following: "l cortify that in the performance of the work for which this permit is ittsuet NV4%0" ttft=ma^s compensa- <br /> tion laws of California.",! PERM If/5ERVl 5 <br /> The applica t must call for all required inspections. Complete drawing on reverse side. . <br /> Signed <br /> Title: f -- Date'. <br /> r T-A) <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by - Date r r r - Area P <br /> 7- Inspection b S <br /> Pit or Grout Inspection by Date Final Ens p Y Date p <br /> Additional Comments: S_ �WillI&M 1-010W/7� <br /> Applicant - Return all copie to: San Joaquin County Public Health Services Zq,So <br /> Environmental Health Permit/Services ! <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO `AMOUNT DUE. AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. � <br /> 13-24(AEV.s/A5) <br /> EH u_m <br />