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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 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 11 <br /> La _.1. <br /> Job Address _ ` -.�1 �5A _ City Lot Size/Acreage <br /> Owner's Name Address � P� S- Phone <br /> r &�AL <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT In DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring Well G7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> 0 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia,of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy- Type of Casing_ Specifications ' <br /> ('I Public (.I Other ll Delta I Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L3 Type of Pump _S/ H.P. �2 State Work Done <br /> Well Destruction ❑ Well Diameter N pealing Material & Depth <br /> Depth r Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial,.r.. Other <br /> Number of living units: Number of bedrooms <br /> _Character.of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Con"' tt+tetat <br /> PKG. TREATMENT PLT. Cl Method ht�►Ts <br /> Distance to nearest: Well Foundation Property Line <br /> vVED <br /> JU 1992 <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation j PropertyNiiML4 -9_7H) (, S <br /> -. _---Edd.V_I.RU.11 UE.N_T_AL_�IP-AlT��NILS i;_)N <br /> SEEPAGE PITS 11 Depth Size Number. ---- { <br /> SUMPS Ll Distance to nearest: Well Foundation^ Property_Line_ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application andr1hat the work will be done in accordrq'e with..San.Joaquin county ordinan tate 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 per n'n such'manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the foil wi g: "1 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 Ca'f n€a." <br /> The spell nt st call for all wired ins coons. Complete"drawing on rev r side. <br /> Signed Title: Date: <br /> f ! FOR DEPARTIVIMT USE ONLY <br /> Application Accepted by , �'{ Data Area <br /> Pit or Grout Inspection by —__ Date Final Inspection by A A Date Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services w' tom <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDGSH ECEIVED BY DATE PERMIT'N0. <br /> INFO �/y <br /> . EH 13-24(REV. /NSI <br /> EH 14.25 c� <br />