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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Cr ENVIRON,ONTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009,, STOC%TON, CA 95201 <br /> y <br /> PERMIT EgPIRES 1 <br /> i YEAR FROM DATE ISSUED <br /> w (Complete in: 'Iriplicate) <br /> Application is hereby made to San <br /> !Joaquin County for a permit to construct and/or install the work herein described. This <br /> F 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 /> mt C y _ <br /> Job Address Cit � t Lot Size/Acreage' r <br /> Owner's Name7-(` `7'�n � A <br /> Addr�ss � f:�+Z � _.._ Phone! <br /> Contractor 01AJ " Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (l DESTRUCTION D Out of Service Well ❑ <br /> G PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERMonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PR <br /> DISPOSAL FLD. PROP.'Ll <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> '��?NTENDED`USE � -TYPE-OFaVVEL"L-��='---_PROBLEM ARE-pr�C—ONSTRiit TION�PE61FdGA710N` _ <br /> f 1 Industrial a [ Open Bottom ❑—Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> 9 <br /> f'1 PubliSpecifications <br /> c L1 Other f i1 Delta Depth of Grout Seal Type of Grout <br /> I I Ifrigation q <br /> pprox. Depth I I Eastern Surface Sea{ 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 �Y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted it public sewer isavailable within 200 feet.) <br /> Installation will serve: Residence,.... Commercial Other <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> .-I- � _ -- r Method of Disposal ; <br /> Distance to nearest:-, Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that i have prepared this application:8nd that the work will be don; 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: "I certify that in the <br /> employ an performance of the work for wfiich..tliis permit issued, I shalt not <br /> P Y y person in such manner as to become subject to workman's compensation laws of California." Contractor's Wrin1�01 sub-contracting si4hature <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 must call for all required inspections. Complete drawing on reverse side, y �' <br /> Signed X �-� <br /> Title: jl Z a <br /> Date.— <br /> IRR <br /> ate:'R DEPARTMENT USE ONLY <br /> Application Accepted by —(QA L - <br /> .d Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> 3 <br /> Additional Comments: Date <br /> - <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE WAMOUNT REMITTED CK <br /> RECEIVED BY ATE PERMI7'NO.�ob EH 13-21(REV.I/K Sl C <br /> £H 11•ZE 111 <br />