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,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (Complete i-n-Triplicate:) <br /> 1 <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Addres r, � r5_'.' ��tl�ec ! CityLot Size/Acreage <br /> -k p <br /> Owner's Name _ - (_ l/�/ ress I � e — + Q <br /> I <br /> Contractor Address lIkI' .License No. ��n�13 Phone <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR 0 OTHER .❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _A0. " SEWER LINES DISPOSAL FLO.1 PROP. LINE _Z—Z& "A � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> =YiNTENDEO-USES—T-YPE=OF-WELL-.—PROBLEM.AREA:- CONSTRUCTION-SP_ECIFICAT-10NS----.— <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation � <br /> Dia. of Well Casing <br /> Domestic/Private I Gravel Pack 0 Tracy Type of Casing pl/`G Specifications � <br /> I'I Public Cl Oth r I-•1 Delta Depth of Grout Seal Type of Gr ut 4s V_ 1, i./n <br /> ! I Irrigation d Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done. <br /> Sealing Material & Depth \ <br /> Well Destruction ❑ Well Diameter nB eP <br /> Depth r Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system pey11t�srwor is <br /> I available within 200 a 1111 11 <br /> installation will serve: Residence_ Commercial _ Other RECEIVED y <br /> Number of living units: Number of bedrooms —_- Ju N + 6 199 <br /> Id <br /> Character of soil to s depth of 3 feet: f b _—� _Water tat§ deg i .7 <br /> SEPTIC TANK ❑ Type/Mfg y Capacity No. Copp1V.1�EAV IN �7Y <br /> PKG. TREATMENT PLT.❑ Me !) (`R <br /> Distance to nearest: Well Foundation Property Line `l <br /> Ilk Er <br /> LEACHING LINE DNo. & Lengtki'af linea /Toral lengthEN W <br /> (� <br /> FILTER BED C1 Distance to nearest . Well Foundation ProPI14 �i <br /> . . <br /> 1992 <br /> SEEPAGE PITSi 1 Depth Size Number LTHSUMPS D Distance to nearest: Well Foundation F i ,RQ, ICES <br /> L- <br /> DISPOSAL PONDS ❑ I MIT/ E <br />- " 1-hereby-'cartify-thatl have'prepared-this-applicatiomand;that-the wok will•be-done in-accordance with San-Joaquin-county-ordinances,-state-laws;and- <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 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 V <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 compansa- <br /> tion laws of California." <br /> The applicant ust call for aH r uired inspections. Complete drawing on verse-sid ; <br /> Signed % Title: Date: <br /> FO EPA ENT US LY <br /> - Ni <br /> Application Accepted byDate Area <br /> Pit or ut nepection by Date A Final Inspection by Date <br /> Additional Comments; 9 �� j t <br /> Applicant - Return all copies to: San Joaquin Zu.ty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95202 <br /> iN AMOU/NTT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . EH13-21 IREV.Irnel ,`-'— �"" •�/y t J(�� <br /> EH 14.75 <br />