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f <br /> 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 /> 't 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 Healtherviees. <br /> �7 /� j �� : <br /> I C/ W <br /> Job Address 1 � City Lot Size/Acreage <br /> i <br /> CL <br /> ! Phone <br /> j Owner's No (//Address (� /7/�/c�, <br /> Go tie or... .. I kw( Address_ A License Iia. Phone <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> L.� Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER ❑ C7 <br /> I DISTANCE•TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLIT. PROP. LINE <br /> ;1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Welt Excavation _ Dia. of Weil Casing <br /> ® Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_. Specifications 14) <br /> 1'l Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> f I f Irrigation _Approx. Depth II Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ElWell Diameter Sealing Material & Depth <br /> ,- - filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 EPAIRI DDITIONr DESTRUCTION I i lNo septic system permitted if public sewer is <br /> �ji ' available within 200 feet.) <br /> -installation will_serve;._Re idence� Commercial Other— <br /> Number of living units: Number Of bedrooms <br /> Character of soil to a depth of 3 feet: '-ZZJy� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j LEACHING LINE No. & Length of lines Tonal length/size <br /> I FILTER BED ❑ Distance to nearest: Well 512 Foundation_ /p Property Line <br /> SEEPAGE PITS l 1�,,Depth Size — Number ' <br /> SUMPS LI 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 compensati6n'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, l shall employ_persons subject to workman's compensa- <br /> tion laws of California." <br /> v <br /> The applicant st I for al r re inspections. Complete drawing on reverse si <br /> Signed Y Date: <br /> FOR DEPARTMENT USE ONLY T <br /> � d <br /> Application Accepted by •- - - Date Area <br /> Pit or Grout Inspection by Date Finil Inspection by Date3 <br /> Additional Comments: <br /> a <br /> Applicant - Return all copies to: San Joaquin County Public-Health Services J <br /> f Environmental Health Permit:/Services <br /> l{ 445-N San Joaquin, P 0 Box 2009, Stkn,G 95201 <br /> ) FEE �__ `/�rv{�.`►Y1�, <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY,, DATE PERMITNO. <br /> r -� ice.ti /1 <br /> i EK 13.24[REV.r/w6i ,�r� / C.0 c7 _�o� �_�'V"Y-'� - -- ��' ���]3 -. 73- <br /> Q r� <br /> EH 14.26 <br />