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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> N Q vo+K <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ` P O BOX 2009, STOCKTON, CA 95201 <br /> k IPERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> I (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 couplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' City Lot Size/Acreage ti�/� <br /> r° Job Address <br /> Phone <br /> Owner's Name !! <br /> 4 Contractor 3 Address License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION ❑ out of Service We11 L1 <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {� <br /> Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation — Dia. of Wel! Casing (J1 <br /> Specifications <br /> ['I <br /> C1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing— <br /> F1 Public CI Other 4 fl Delta Depth of Grout Sea{ Type of Grout <br /> I i I Irrigation _.Approx.4 Depth I I Eastern Surface Seal-Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth I Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION^ INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence! Commercial_ Other <br /> Number of living units: Numbar of bedrooms <br /> i Character of soil to a depth of 3 feet Water ;able depth <br /> . ❑ Type/Mfg Capacity No. Compartments <br /> SEPTIC TANK <br /> 1 PKG, TREATMENT PLT. ❑ 't Method of Disposal <br /> Distance to nearest: Well Foundation , Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: well Foundation Property Line <br /> 3 <br /> SEEPAGE PITS 11 Depth f Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 r <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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 .2 " Ara.— <br /> Pit or Grout Inspection by Date Final ins? ction by Data <br /> Additional <br /> Additional Comments: L" �� <br /> i <br /> f Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13-241REV.r/RS) <br /> EM 144.266 <br />