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o. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <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 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ��_� / # <br /> Job Address e�C i,- City j - Lot Size/Acreage <br /> Owner's Name , —a- &L "JL c Address -Z 3 � T shone Z cqw <br /> Contractor ' rt� t c. Address l 4"x License No�7-6'1Y _—Phoneme-2 -/ -7 <br /> TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT DESTRUCTION >4t of Service Nell Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Cp- Monitoring Well C7 , <br /> DISTANCE TO NEAREST: SEPTIC TANK ZtOp�L_ SEWER LINES _aQDISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLW n'.0 OTHER WELL ✓� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F� t <br /> n Industrial ID Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 04.pomestic/Private RQGravel Pack Irl Tracy Type of Casing-Pyc Specifications <br /> I'! Public C7 Other fl Delta Depth of Grout Seal <br /> Type of Grout <br /> I i Irrigation StMApprox. Depth I I Eastern Surface Seal Installed by A it <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter/ � Sealing Material & Depth ; <br /> Depth _Zo /ff /2(9 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other / t <br /> Number of living units: Number of bedrooms / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/site <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina s <br /> DISPOSAL PONDS O <br /> 1 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: "I certify that in the performance of the work for which this permit is issued. I 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 must call for all required inspections. Complete drawing on reverse side. cc�� SS <br /> Signed X C t,Title: t'l i��Y] Date: Z-ld ~ <br /> R DEPARTMENT USE ONLY q <br /> Application Accepted by Q- Date! Area © '� <br /> f CA At IVK <br /> Pit o Grou Inspection byDate Final Inspection by f Date # <br /> Additional Comments: <br /> ---- V= -1 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Service <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95 D1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> aPERMIT"NO. <br /> INFO <br /> . EH 13.241REV.s/AS) <br /> EH 14"2e <br />