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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 0 BOX 2009, STOCKTON, CA 95201 <br /> • s3 <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. <br /> Lcu <br /> Job Address _�qi? ■- A-?_� CitySize/Acreage <br /> Owner's Name {A. '1ra �` Address Phone <br /> Contractor Address License two. Phone <br /> TYPE OF WELL/PUMP:-.�...,��...,-NEW-WELL-0 -j WELL REPLACEMENT ss, '�-•DESTRUCTION t of Service well Ll <br /> / SYSTEM EPAIR Ll OTHER❑ Monitoring Well C7 <br /> PUMP INSTALLATION Ism _-11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINtS'` � DISPOSAL FLD._10 ROP. LINE _ O <br /> FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS 111n!�} <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJQbS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [ mesticlPrivate Pavel Pack ❑ Tracy 'Type of Casing_ Sp:petGroul <br /> ifications C <br /> •` <br /> 1'1 Public Cl Other fl D`eLta ,_ _Deq+h of Grout Seal n T <br /> I I lrrigation / Approx, Depth I/FEastern Surface,Seal Installed by <br /> Repair Work Done fes' Type of Pump 46b H.P. 3 State Work Done rrid AR.AJA Itur <br /> Well Destruction We"'Well Diameter /I& Sealing Material & Depth [� <br /> Depth Filler Material i Depth _ <br /> 4 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITIOfd I I DESTRUCTION MINo septic system permitted if'pu tic sewer is <br /> f available within 200 leet.l <br /> t, Installation will serve: Residence— Commercial Other , <br /> Number of living units: Number f bedrooms <br /> Charader of soil to s depth of 3 feet: ZWater table depth <br /> SEPTIC TANK ❑ Type/Mfg opacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ 'Method of pi�posal l <br /> Distance to nearest: ell Foundation Property Line <br /> LEACHING-LINE- --0 No. & Length of lines Total length/size - <br /> FILTER BED n Distance to nearest: W Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size n iNumber f <br /> SUMPS 0 Distance to nearest Well Fo dation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this app ication and that the work will be done in accordance► 1th San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County.. •I r� f ' <br /> Home Owner or lice ent'a signature cenifisi the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any per n in,such nn as to become aub to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the f lowin : "I cerci that in a norm o of the work for which this permit is issued,'l shall employ persons subject to workman's compensa- <br /> tion laws of Calitor a." <br /> The applic Ca <br /> mu c or II r e Co awing on r side. �r <br /> Signed Title: r Date: <br /> ' R DEPARTMENT SE O LY <br /> Application Accepted by Pate. l� a Area <br /> Pit o Gro nspsction by DD�alee Final'Inspection by Date <br /> Additional Comments: <br /> Applicant - Retu n a11 copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 A.San Joaquin, P-O Box 2009, Stkn, CA 95201 <br /> 4 FEE AMOUNT DUE AMOUN74iEMITTEO CASH RECEIVED BY DATE PERMIT'NO. <br /> I <br /> • EN13-241REV.r/K51 s�� � �� 3l r1 Z 2�37 <br /> EH 14.20 <br /> '�'� WP - - <br />