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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Com plete .in. Triplicate) <br /> Application is hereby made to.Sea Joaquin County for a permit to construe and°1$install d theeRiiles'.'andwork eRegulationsaof' Sans <br /> applicetioa is'made in coitar+lience with San Joaquin County Ordinance iio. 5 9 Yr <br /> Joaquin County Public Health services. I <br /> `� ' �'• City` ` \ '`. Lot Size/A"creage' — <br /> Job Address <br /> Phone <br /> Address <br /> ' r <br /> _ I <br /> Owner's Name <br /> one <br /> Cont r <br /> Address License �S�RUCK ION 4ui l Ph <br /> ractor P ' t of Service We D <br /> NEW WELL ❑ WELL REPLACEMENT C7 D <br /> TYPE OF WELLIPUM " Monitoring Well C] <br /> SYSTEM REPAIR.❑ O7HER..C7 . <br /> tsTANCE TO NEAREST S <br /> ? - PUMP INSTALLATION ❑• Di5P0 <br /> SEWER LINES SAL FLD • <br /> EPTIC TANK P <br /> ROP LI <br /> € 0 �"' . ., _. ., AGRICULTURE WELL OTHER WELL. ' 1T51SUMP5 <br /> - s FOUNDATION _t <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' i <br /> `. pzManteca; .m Dia. of Well Excavation <br /> Dia. of Well Cas ng <br /> n Industrial ClD Open Bottom. <br /> P Domenic/Private ❑ Gravel Pack ❑ Tracy Type of Casing u <br /> Specifications <br /> — <br /> Typo of <br /> .❑ Delta <br /> Depth'ot Grout"Seal Type Gr`o t <br /> I"I Putilrc 4 ', f T 011ier' , <br /> I i Irrigation , �_ Approx. Depth. I (.Eastern._. Surface•.5aa1 installed by _.. <br /> 4 State Wok Done <br /> U TYpof Pump H.P. <br /> Repair Work Done ' <br /> ..Seal-ing Hattrial 8 Depth• - <br /> `... <br /> Diametei <br /> Weli'Destruction D' Well' <br /> �,. <br /> Depth Mater <br /> Deptjai fi Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I REPAiRIADDIT_ION I I ISESTRUCTION I l atvaiiabke�wthin.,2t]0 feet�jed if public sewer is <br /> Installation will serve: Residences Commercial_ Other <br /> Nlamber,gt;living units - Number of bedrooms <br /> Waterlable.depth <br /> chiract,0 coil..to-e depttiof 3 feet: j 1 No. Compartments <br /> SEPTIC TANK: Type/Mfg 1 i Capacity'` -�— <br /> / Method of Dtspos�a 1 <br /> PKG TREATMENT PLT..❑ <br /> a . <br /> —Distance to nearest:: Well:• Foundation i Property Line <br /> �R,. I . <br /> ' .. _ - <br /> - 2 D .. Total length/size <br /> BLEACHING Ld[+fE No 6 Length of lines 7 <br /> !P operty Line „. <br /> C1 Distance...to-Distance Well Foundation . -=-� ' :i <br /> a ' <br /> .FILTER-BED ! <br /> SEEPAGE,PT � er <br /> • Sae Numb <br /> ITS <br /> Depth , <br /> Pro Line' <br /> SUMPS LI .:Distance to nearest: Well Foundation - - I Party " <br /> DISPOSAL PONDS O ` <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance vMh Sante:Joaquin county ordinances state laws and ' <br /> Home weer olicensedtagent s signature certifies the foilow,ng:_'I cettifY that in dhe',performartlaws `if g shalt not I <br /> rules and regulationsof <br /> reprt In Such manner as to become tiublect to Workman s',compensati 'r it is issued I shall emploC6ny perrsonslsubj subject to workman's c signature <br /> e of the wo""tic for which this perms is issued, I <br /> ractoes <br /> ring <br /> employ any pe <br /> 1ti" <br /> - . ompensa <br /> k certifies the totlowing:"I certify,that in the performance of the work fbr which this perm t's , <br /> a <br /> tion laws of California." - <br /> The applicant must call for all:required inspections. Complete drawing on reverse;side. 4 <br /> Date: <br /> Signed ti\, 6 Title: <br /> FOR DEPARTMENT USE ONLY .v �- <br /> \i ? <br /> _.. <br /> APPlication Accepted by Date 9^J i Ar ea, <br /> _. <br /> 'Date <br /> Data= Final inspect`gn by, <br /> Pit or Grout Inspection by <br /> _ , . <br /> Additional Comments: .. " <br /> Applicant Return all 'cop les to; in Joagitip"CoCiilty'Piiblie'Hea'th Services <br /> Environmental Health Permit/Services <br /> t <br /> „ <br /> 445.=N-San Joaquin, P O Box--2009,' Stkn; CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED' CK- "` " RECEI.VED'BY '. DATE PERMIT'NO. <br /> FEE.. + CASH <br /> INFO Q.. 9 <br /> . EH 1 -21(EH 14-26 REV.vnSj <br /> i <br />