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... day • <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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,';; <br /> 44 (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 j <br /> application is roads in coerpiiance with San Joaquin County Ordinance No.' 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health'Services. <br /> VAAEJI <br /> Job=Adares's tr Lot3Size/Acreage'yl.. <br /> IY p <br /> k <br /> l <br /> rs Address Phonem4��fAW_45 C4 <br /> acto Addres ow_License No. Phon <br /> ti a! <br /> s <br /> TYPE OF WELL/PUMP: P NEW WELL OK WELL REPLACEMENT ❑ DESTRUCTION ® out of Service Well D <br /> PUMP INSTALLATIOWK — - &SYSTEM REPAIR„�Cl._ �,. -.,.07HER.0 Monitoring 11e11 <br /> -, <br /> S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLD. PRO�r�INE <br /> ` FDl1NDATION 4GRICUL"TURE=I/VELL OTHEfl WELL PTI S/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) industrial XOpeh Bottom_ - -i] Manteca Dia. of Well ExcnavpAtion Dia. of Well Casing <br /> i <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing i'18� k Specifications <br /> FI Public Cl Otter fl Delta Depth of Grout Seal �d0,_ Type of Grout L <br /> I' Q�Pitt�� <br /> rrl I Irrigation 3,EMApprox. Depth I I Eastern Suriaca Seal Installed by �.. <br /> Repair Work Done L7 Type of Pump H.P. State Work Done {h <br /> Weli Destruction 0 Well Diameter Seating Material & Depth <br /> Depth l) Filler Material & Depth 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of-kfeet: - Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0I'I Method of Disposal ; <br /> Distance to nearest: Well Foundation Property Line <br /> II. { <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> II � <br /> SEEPAGE PITS 11 Depth - Size Number' <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O A . <br /> s 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 V <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 shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th wing: "I certify th" in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> r tion la of Cali rola." H # <br /> ,The pplicant m t call /r ired inspections. Complete drawing on arse si _ <br /> Signe Title: A�/ �Z = --- - --- Date: '� 3 <br /> FOR DEPARTMENT USEONLYI <br /> F <br /> ea <br /> Application Accepted by � Date J <br /> Pit o Graut nspection by Date Final inspection by Date <br /> Additional Comments: I' G / <br /> Applic nt - Return alli[copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> f7 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT;DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . o ��� do 3- 0 <br /> • EN I3-241AEY.i/n SV Q�1 'O� �— �l �� <br /> EH t4.2a I tV nC / <br />