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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 Services/. / /.- ''n <br /> Job Address �l /_ �.� , G 4� I ��� � Cit -C <br /> [2_1�;11Z �Ylze/Acreage <br /> Owner's Name I _ P r Address y t-/ _ _ _ Phone <br /> Contractov, l �-7/71nLL 1. ok,/S_/Address sl•0 LJ, 5 - -ID-acense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (S; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE tYKQ OF WILL PROOLCM AREA CONSTRUCTION SPFCIFICATION4 <br /> (1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ( I <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ ____.__ Specifications <br /> I') Public ( 1 Other ❑ Delta Depth of Grout Seal Type of Grout __ n <br /> I Initiation __ 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 i Depth <br /> Depth Filler Material h Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION P i-r5ESTRUCTION I I (No septic system permitted if bublie sewer is <br /> available within 200 feet.) <br /> Installation will serve: Re 'dance ✓ Commercial Other <br /> Number of living units: Number of bedroo.rns-`�L- <br /> c <br /> Character of soil to a depth of 3 feet: `-�/E}JC/� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Cf)/iWk—i-" r-� Capacity ":�-0 L-) No. Compartments �--. <br /> PKG. TREATMENT PLT. ❑ Method of i osa� <br /> Distance to nearest: Well Foundation `7 Property Line <br /> LEACHING LINE L-) No. 6 Length of lines T�WI length/size <br /> FILTER BED t'L1_ 8istance to nearest: Well _ � Fou anion Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS l_I 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, 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 subcontracting signature <br /> certifies the following: " fy that i he pert anc o e w k for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> (tion lam California. <br /> The applica t m t cal for all r quir nspe.c ns. rmpl e drawiinn on verse side. \ �f <br /> Sig Title: Date: <br /> (� �F =NT USE ONLY <br /> Application Accepted by (�Ju\�� \\��jj' Date ^ Z Area <br /> Pit or Grout Inspection by �f]Date Final Inspection by - Date ! 1 7 <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 Rox 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO, <br /> • EH 1324(REV,rix5) v7 1p7v -a7 `� <br /> EH 14 20 d� c <br />