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SAN .JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 44+5 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED Is <br /> (Complete in Triplicate) <br /> describe <br /> tall <br /> work <br /> Application is <br /> is hereby made <br /> cagiliance withuSaanCJ aquinor a countyrOrdinancenNo. 549gando1862sa.nd theeRules and Regulationsdof Sans <br /> I <br /> in <br /> app ' <br /> Joaquin Count Publi He lth Services. <br /> 2 S City Lot Size/Acreage <br /> Job Address i <br /> Phone <br /> ess <br /> w at Nam � I <br /> i e N Phone + <br /> t t� DESTRUCTION ❑ ouT of Service Well L <br /> NEW WEL WELL REPLACEMENT t otitoring Well Ll <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> 0 NEAREST: SEPTIC TANK SEWER LINES -- DISPOSAL FLD, PROP.V <br /> LI <br /> DISTANCE T <br /> FOUNDATION.r AGRICULTURE WELL OTHER WELL-- PITS/SUMPS t* i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing r <br /> ❑ Open Bottom [:1 Manteca Dia. of Well Excavation r i <br /> n Industrial Specifications <br /> Type of Casing- <br /> or" <br /> or" tic/Private 0 Gravel Pack f ❑ Tracy Depth of Grout Seal Type of Grout <br /> i'1 Public f 1 Other 1-7 Delta t <br /> —.Approx. D h I Eastern �ti Surface Seal Installed by <br /> I I Irrigation <br /> p 71 <br /> State Work Do <br /> Repair Work Done U Type of PumH.P. <br /> Sealing Material & Depth <br /> Well Destruction O Well Diameter Filler Material 6 Depth <br /> IDepth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I TRUCTION I I DE5availabINo lefwithin 200 feet.] <br /> d 'f 'blit sewer is <br /> k Installation will serve: Residence— Commercial— Other <br /> - <br /> Numfzer-of-living-units: Number of bedrooms Water table depth ' <br /> Cfiafacter of.soil to a_depth of 3 feet: No. Compartments <br /> . � --- <br /> ! 1 <br /> 'ti,. ❑ Capacity <br /> SEPTIC TAI'JK- TypelMlg Method of Disposal i <br /> PKG. EfY <br /> �7REATM7 PLT.'❑ r property Line <br /> Distance to nearest: Well Foundation — <br /> =. <br /> k� � � Total length/size >> <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTEI�.BED�=-�""�`n—Distance to�ne�arest:- Foundation._ <br /> y� Si:e'"'.��.-u-•�'....':,-. Number <br /> SEEPAGE PITS l I Depth <br /> SUMPS LI bistante to nearest: Welt R <br /> Foundation Property Line <br /> DISPOSAL PONDS_ 01 , t '# V <br /> I hereby certify that I have in accordance with San <br /> prepared this application and that the work will be done <br /> 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 intheperformance of the work for which this permit is issued, I shall not <br /> ff employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or�ub-contracting signature <br /> E "4 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> certifies the following: <br /> EEEE tion laws of California." {I <br /> The appli a st call eqed inspections. Complete drawing on revs side. <br /> Date: 40 / <br /> Title: i <br /> igne i <br /> f R DEPARTMENT USE ONLY ` <br /> _ Date L- Area .. <br /> Application Accepted by <br /> Dat <br /> Pit or Grout Inspection by Date <br /> Final Inspection <br /> Additional Comments: <br /> f Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK RECEIVED BY DA E PERM11'NO. <br /> INFO /D _ <br /> . EH 13-24 tREV.1 N S! ,t.•y� ` D <br /> EH 14-25 <br /> k <br />