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r� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> n V 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 /> (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 costpliance vlth Sar. Joaquin County Ordnance Mc,. 5109 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Q� <br /> Job Address I g SI o AVSTIIv Cit" M TC^ _ Lot SizeiAcreagr <br /> Owner's Name _.3. & __ �`f�O� Address n' __._ __ Phone <br /> CGnlractox CAU)Le Address � !30 'BYTt -4j r'4UeL+cense No.�.L�.L!-�8 Phone 823 "65f3 <br /> TYPE OF WELLrPUMP NEW WELL r1 WELL REPLACEMENT DESTRUCTION 7 Out of Service Welt ( I <br /> PUMP INSTALLATION 2 SYSTEM REPAIR OTHER Monitoring Well <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 'I Industrial O Open Bottom ( Mantecs Dos of Well Eucaysaon Dia of Well Casing <br /> ( ! Domestic;Private Ci Gravel Pack 1-1 Tracy Type of Casing Specifications <br /> 1" Pnblrc f 1 Other t , Delta Depth of Grout Seal ._ Type of Grout -= <br /> ii Irollation _ Apfxoz Depth 11 Eastern Surface Soot Installed by <br /> Repao Work Done U Type of Pump H P ___. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth _ <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION : I REPAIRiADDITION ;#* DESTRUCTION I' (No septic system permitted if public sower ,s <br /> / available within 200 feet l <br /> Installation will servo. Rp,de/qce..JL Commsrcur Other <br /> 'umber of living units: J,L Number of Aedrooms-3 <br /> -haracter of soli to a depth of 3 reef: cAuny r1% Water table depth <br /> SEPTIC TANK O Type/Mig IE _ Capacity 0.0 No. Compartments r <br /> PKG. TREATMENT PLT. 0 % l Method of pisposal <br /> 2 1 <br /> Distance to nearest: Well �� Foundation Propeny Line <br /> LEACHING UNE L'rNo. 8 length of lines Total fengthisoze _ <br /> FILTER BED L9 Distance to nearest. Well Foundation Propeny Lone <br /> SEEPAGE PITS I-r—Deplh Size _ _ ' _ Number <br /> SUMPS L! Distance to nearest: Well �S J' - Foundation Property Line <br /> 60 <br /> DISPOSAL PONDS 0 <br /> 1 hereby cenify that I have prepared this application and that the worn will be done in accordance with San Joaquin county ordinances, sure laws, and <br /> rules and regulations of the Sm Joaquin County <br /> Home owner or licensed agent's signature osnifies the following "I cantly that in Ine performance of the work for which this permil is issued. I shell not <br /> employ any person In such manner as to bee object to workman's compensation laws of Cabfor" Contractor to hiring or sub contracting signature <br /> eendies the following: "I certify that in the pert mance of the work for which this permit is issued. I shed employ persons subject to workman's compenu <br /> tion laws of California." f <br /> The applocanl m 111 for MI r in Pons. Complete drawing on re Ise sods <br /> Signed X � Title: Date: 2 <br /> 9- �+3 <br /> FOR DEPARTMENT USE ONLY <br /> O <br /> Application Accepted by � Date _I-to- dL� <br /> Ph or Grout Inspection b //11 _ Days ..} Final Inspection by Date'' <br /> Additional Comments: ��!`/� ��.�lO �f "� <br /> Applicant - Return all copies to: San J.,aa .._ County uhlic Health Services <br /> Environmental Health Permit/Servicev <br /> 445 N Sea Joaquin, P U Box 2009, Stkn, CA 91,201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO <br /> INFO CASH <br /> fP. InfV . .S. . �, ;, ti r 9,3 - o <br /> fPl tl se <br />