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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 'Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> iapplication is made in compliance with San Joaquin County Ordinance No. 51+9 and 18b2 and the Rules and Regulations of San <br /> ,Joaquin County Public Heal�t/ <br /> ' <br /> h'�Services� <br /> f � [ S _ City Lot Size/Acreage <br /> Job Address { r <br /> - Phone <br /> Owner's Name t 'Andress <br /> CS <br /> kpL iCOfi � � dre se No. Phone r <br /> tr <br /> .TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well C <br /> E MonitoringWell <br /> x PUMP INSTALLATIO SYSTEMrREPAIR �7 OTHER C7 <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> €(3 Industria! ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing/ <br /> �}�emesticlPrivate Cl Gravel Pack C] Tracy Type of Casing_ <br /> Specifications f <br /> �k rl Public C] Other n Delta Depth of Grout Seal Type f Grout <br /> f „ l I t,,igatjor, ____,Approx. Dept l EaEastern III Surface Seal Installed by <br /> (Repair Work Done 0 Type of Pump H. Z' State Work Do <br /> Kzku <br /> Well Destruction ❑ Well Diamalk ,_( �`__� Sealing Material & Depth <br /> Depth ++ Filler Material & Depth <br /> 'TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION i ! DESTRUCTION I I lNo availableiw thin 200 feetit�ed if public sewer is <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms <br /> r"I Character of soil to a depth of 3 feet: Water table depth <br /> SEP TANK TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PK Ci: TREATMENT PLT.❑ Method of Disposal <br /> ¢ Distance to nearest: Well Foundation Property Line 5 :/ <br /> r <br /> LEACHING LINE ❑ No.'s Length of lines Total length/size <br /> FILTER BED � C7-Distance to.nearest: Well Foundation Property line <br /> SEEPAGE PITS 11 Depth Size Number <br /> j SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> i 2a6SAL PONM '� ❑�' 4 (� <br /> t hereby certify that I haus prepared,this,application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an U <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, E shall not <br /> ampioy 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 subjectt� o workman's compensa- <br /> tion lawa_of_Califor-nia <br /> I The applicant u call fo re inspe, ions!Complete drawing on rever side. <br /> Sig d Ive Title: Date: <br /> .I <br /> FOR DEPARTMENT USE ONLY <br /> 4 Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final inspection by Date <br /> Additional Comments: c�Y 2 ' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> P Environmental Health Permit/Services <br /> 445 N San Joaquin, P O_Box 2009, Stkn, CA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CK � RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH n <br /> . EH 13-24 IREV. x 51 Ss�r ��� +✓ <br /> EH t{•]e �•! <br /> 'f <br />