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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j (Complete in Triplicate) <br /> Thi <br /> Applicais hmadeIncocompliance withuSan County <br /> Joaquin Counr a tyrordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> theeRules andherein <br /> Regulations of Sans <br /> application <br /> Soaquin county Public Health services. <br /> City Lo Size/Acreage ,1 <br /> Job Address a° t <br /> e <br /> PO gJ Phone i <br /> fv Address <br /> Owner's Name <br /> Z £ ,{ <br /> - / rte , ,7�f/eoP License <br /> Contractor � `���Phone <br /> Address <br /> kWELL REPLACEMENT 11 >aESTRUCTION 0 Out of Service Well ❑ i <br /> E TYPE OF WELLIPUMP: NEW WELL ❑ Monitoring well C3SYSTEM REPAIR-Cl_„� s„. y� „OTHER O <br /> PUMP`�NSTALLATION C7� �. ,_ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITSISUMPS <br />� , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS TDia. of Well Casing <br /> li Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications.. — <br /> Ili Type of Casing- <br /> Ca DomesuclPrivate ❑ Gravel Pack C] Tracy Type of Grout <br /> Fl Public <br /> fa Other L1 Delta Depth of Grout Seal <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by <br /> I H P State Work Done <br /> Repair Work Done U Type of Pump Sealing Material & Depth rr <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material & Depth l <br /> ' <br /> par <br /> TYPE OF SEPTIC WORK: NEW INSTAL REPAIRIADDITION € I DESTRUCTION l I (Noavaseptic systele shin m feet.) <br /> 01 <br /> if public sewer is <br /> Installation will serve: Residence!°, Commerciat_ Other �; t <br /> Number of living units: _L_ i Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:; 4^ No. Compartments <br /> g _ <br /> SEPTIC TANK- ❑ Type/Mf �+ -.Capacity--- <br /> �- Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ' <br /> Pra ert Line�Z_!_ <br /> Distance to nearest.: Well��_ Faundarion p Y <br /> r`r Totat length/size <br /> LEACHING LINE Cl No. & Length of lines w <br /> '�- T Property Line <br /> FILTER BED ❑ Distance to nearest: Well 1�^ � Foundati n <br /> i SEEPAGE PITS 11 Depth S1ze£1 f-�- a� — Number <br /> SUMPS 11'�Foundation Property Line A�/` <br /> Distance to nearest: Wei' - � t: <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquinco county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County ; y <br /> Home owner or licensed agent's signature certifies the following:."I certify that in the performance-of theAvork for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workm: an'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 persons subject to workman's compensa- <br /> i tion laws of California." w« F- <br /> The applicant must call for all require inspections.Complete drawing on reverse iidew �„ <br /> Signed X <br /> Title: Date: <br /> f <br /> OR D1iP TfNENT LY <br /> �f Date _ Aref� <br /> Application Accepted by t <br /> Date Final inspection b <br /> Pit or Grout inspection by <br /> . Dat <br /> Additional Comments: j <br /> r <br /> Applicant - Return all copies to: San Joaquin County,Public Health Services i <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> FEE <br /> AMOU T DUE - AMOU T REMITTED CASH �.-- RECE ED.Ely.. - ,.,---.DA E <br /> -- <br /> EH-13 24-0411P <br /> J <br /> EH 14-Ia <br />