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` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Q- 47- p . <br /> Job Address <br /> 7 4 oo City Lot Size/Acreage R V v " '-'�, <br /> Phone <br /> ,3 ZOO( tp�k 17 <br /> `` Owner's Name T Address <br /> I icense No, Of <br /> 13 ?hone �I0 <br /> Contractor �e, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> Monitoring Well G7 <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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> g ,[r) Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Easing_ Specifications \ <br /> i'I Public! 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation' �- -pprox, Depth t I Eastern Surfaee+Seal Installed by <br /> I Repair Work Done .0 Type o Pump H.P. State Work Done _ Q <br /> Wei! Destruction ❑ Well Dia .!ter Sealing Material & Depth <br /> i <br /> Depth 1 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIRIADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Rest once Commercial— Other'— <br /> Number of living units: Number of bedrooms_f _ p <br /> Character of soil to a depth of 3 feet: s -i �a d Water table depth h <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> t PKG. TREATMENT PLT. ❑ t. ,. Method of Disposal-/00 <br /> isposal �\ <br /> Distance to nearest: Well"' �o <br /> -1— Foundation Property Line FL,dO.& <br /> LEACHING LINE ❑ No. & Length of lines 111 29 Total 1e4gtli/size a' <br /> 'FILTER BED 11 Distance to nearest: Weil 69Foundation 1Property Line _ 6 <br /> SE AGE PITS 1 I Depth ize __ Number. <br /> UMP LI Distance to nearest: Well Foundation 7 Property Line <br /> iSPOSAL PONDS-. ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance-W' San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County. F <br /> t Horne owner or licensed agent's signature certifies the following;-"I-certify that in the performs nce-of.the work for which this permit,;s issued , I-shali not <br /> i employ any person in such manner as to become'.subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> e 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 comp antta- <br /> tion laws of California." <br /> I :The applicant I fpr all real a inspections. Co late drawing on r verse side. <br /> Signed X ���j1y ° Title: i+ Dater � 6 <br /> r } r-' �i <br /> FOR DEPARTMENT USE ONLY <br /> E _ Applicat�n" <br /> by Date LLQ—( Area <br /> Date nal Inspection by Date V / <br /> t - � 4 j <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�_O Box 2_00_9,_Stkn, CA 9.52.01 <br /> �. FE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY O TE PERMIT'NO. <br /> INF <br /> 77/& <br /> xL / // � <br /> aEH13=2�'Ir[€V-1/KSI <br /> EH tl-2e -° ! <br />