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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r Application is hereby made to Sass 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 1$62 and the Rules and Regulations of San <br /> k Joaquin County/Public Health Services. n <br /> l ob Address 7 V � L -r� I� — Ci[y - Lot Size/Acreage <br /> r `� e- -Tpj es cm-rs !J s Phone <br /> d Owner's Name <br /> �Contlactor Address License No. Phone <br /> P TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o put of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring w 1 fi <br /> Cis Ce H a r-� rt�7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI13E <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ! n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> to Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'I Public [-I Other n Delta Depth of Grout Seal Type of Grout O <br /> 11 Irrigation Approx. Depth I I Eastern- Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. '•- State Work Done <br /> t Material <br /> Wel! Destruction ❑ Well Diameter Sealing & Depth <br /> I Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <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 ❑ Type/Mfg Capacity' No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,J ; Method of Disposal <br /> Distance to nearest: Well Foundation Pprty Line^ f i <br /> LEACHING LINE CI No. &'Length of lines Total length/size , <br /> FILTER BED FI Distance to nearest: Weil Foundation Property- Line + ; <br /> 1 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 <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 /> tion laws of California." <br /> JSigepplica must call for all req red ins tions. Complete drawing on reverse side. <br /> ned Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by 411�A A A <br /> Date �r �,Z Area y •- - - <br /> Pit or Grout Inspection by Date Final Inspection byy`��" /// � r"— Date L� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> { 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDel Ck RECEIVED BY DA PERMITN0. <br /> INFO <br /> . EM13-241REV,�inss c/'�tn� <br /> �M 1 <br /> EK 11-26 L �+ <br />