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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 /> 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 Sery ces. <br /> City 40qih"e/Acreage <br /> Jab Address <br /> Owner's Name j,�-� _ Address m Phone <br /> .r P/ <br /> • h 0 icense No. -3 g­ Phone b S� <br /> ContractorWAL Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION L1 Out of service Well <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I f1 Industrial ❑ Open—Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> k C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> ,' �•s��- <br /> Depth Filler Material b Depth <br /> :TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I TRUCTION i I lNo septilablemr thin system permitted if public sewer is <br /> avaInstallation will serve: R srdence� Commercial Other <br /> Number of living units: - Number of bedrooms y. <br /> Character of soil to a depth'of 3 feet: Water table depth <br /> DLF <br /> SEPTIC TANK,t t /Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET.❑ ! Method o1�Dbt:p�sa� <br /> Distance to nearest: Well foundation 1_ Property Line !! VV <br /> LEACHING LINE ❑ No. &.Length of lines r """ Total length/size <br /> FILTER BED CI !Distance�to nearest: Well, �, -- - Foundation Property Line <br /> ... <br /> SEEPAGE PITS 11 Depth f Siie Number <br /> SUMPS_-_ ---._GI_Distance to nearest: Well � —"Foundation Property Line � ` i <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, I shalt not <br /> employ any person in such manner as to becomes orkmen's compensation lawp of California. Contractor's hiring or sub contracting signature <br /> ' <br /> cats following: " ce that in the part n e o he tar which this permit is issued, I shall employ persons subject to workman's compansa <br /> '--lion laws ofCa4r iri.' 3 <br /> The applican must. yelp► to hawing verse sid r r <br /> ' Signed Tit <br /> Date: <br /> O DEP TMENT USE ONLY <br /> Application Accepted by Date <br /> Arey r <br /> Pit or Grout Inspection by Date Final Inspection by ' i Date <br /> Additional Comments: <br /> Applicant - Return all copies to: kSan Joaquin County Public Health Services _tom <br /> Environmental Health Permit/8ervices <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMO NT REMITTED CASH CEIVED BY 91A PERMIT NO. <br /> . EH 13-24IREV.IIR51 Load �a <br /> EH 14.26 <br /> i <br />