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? --- - — - <br /> 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 MIRES 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 /> Job Address °a 3.5"33 r !7/I f �. � dE• City_91142-1011y� - Lot Size/Acreag <br /> I <br /> i <br /> Owner's Name gYUC /7��4,v G Address S'33 �Y• //14 h �-llki e/f Phone { <br /> Contractor H d $ 5oo, Address 6/0A el-oli° vN/ lydo License No,yyYg*9I Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service-We 1 ❑ <br /> # t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J( 4 <br /> n Industrial ( p Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing d��} <br /> ne Domestic/Private Cl Gravel Pack 0 Tracy 1 Type of Casing_ Specifications <br /> I.1 Public C] Other n Delta Depth of Grout Seal Type of Grout <br /> + I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by ( ` <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A DESTRUCTION I I (No septic system Permitted if public sewer is <br /> I available within 200 feet.) <br /> "Installation will serve: Residence Commercial— Other <br /> , � x <br /> Number of living units:,I _ _ Number of bedrooms 3 <br /> Character of soil to a depth�of 3 feet: M r ^' Water table depth �O <br /> SEPTIC TANK. <br /> O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ YY Method of Disposal <br /> Distance to nearest: Well Foundations Property Line <br /> r LEACHING LINE Cl No. & Length of lines '' Total lerigth/size -A <br /> }FILTER BED C7 Distance to nearest: Well Foundation Property Line <br /> ~ SEEPAGE PITS 11 Depth �� _ <br /> p Si:e -� X f x ` Number, <br /> a' SUMPS 04 Distance to nearest: Well /90Foundation 4 �a� Property Lina <br /> ., DISPOSAL PONDS Cl <br /> r t <br /> - - 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: 1 certify that in the performance of the work for which this permit is issued, !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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mucall for al'required inspections. Complete drawing on reverse side. <br /> Signed X Title: D8t$: !i-117 ^ `f <br /> - R DER RTME USE ONLY <br /> Application Accepted by Date tea <br /> Pit or Grout Inspection by Date Final Inspection Dated �� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 11 445 N San Joaquin, P d Box 2009, Stkn, CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY ATE PERMIT NO. I <br /> + <br /> . EH 1741(NEV. <br /> EH 714e <br /> S <br />