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SAN JOAQUIN COUNTY PT})A,IC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> k <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 <br /> inHeoompliamce with SSan Joaquin county ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> city t Size/Acreage <br /> Job Address If J <br /> t � Phone <br /> r Address Well 0 <br /> Owner's Name <br /> Contractor Lrte— Adores <br /> License No� Phone <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL Rof Service Well <br /> EPLACEMENT ❑ DESTRUCTION Cl Out OTHER 0 Monitoring Well Ll <br /> i SYSTEM REPAIR C1PUMP INSTALLATI,ON�� <br /> — <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> t AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> FOUNDATION ____^_�— <br /> F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> n Industrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing_ <br /> ' �DomesticlPrivate ❑ Gravel Pack �❑ Tracy Depth of Grout Seal Type of Grout <br /> I'1 Public <br /> i l Other Cl Delta <br /> I I Irrigation —.Approx. Depth I Eastern Surface Seal installed by <br /> H.P. State Work Done — <br /> i Repair Work Done 4 Type of Pump <br /> Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; I'll NEW INSTALLATION l I REPAIRIADDITION E I DESTRUCTION l I aNailahPerc system within 200 leel1tled,I public sewer is <br /> Installation will serve: Residence T Commercial— Other ti <br /> Number of living units: Number of bedrooms } <br /> Water table depth�_...,.�— <br /> I Character'of soil to a depth of 3 feet: No. Compartments <br /> SEPT,IC'TANK 0 Type/Mfg Capacity - <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to-nearest: Well Foundation <br /> vhf <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines }. . Property Line <br /> FILTER BED n Distance to nearest: Well 4 Foundation <br /> I <br /> Sire Number <br /> r SEEPAGE PITS I I Depth Property Line <br /> SUMPS LI Distance to'nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the_work will be done in.accordance with San Joaquin county ordinances, state laws, an <br /> rules arid 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 /> `,any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> amploy <br /> I certifies the fotlowing: "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 taws of California." <br /> The ap ' ant mus call for all required in coons omplete drawing on� side. <br /> Title: <br /> Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY Z� <br /> Date � L Area <br /> Application Accepted by a%jm ( R <br /> Date — Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> 4 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, Stka, CA 95201 <br /> E <br /> FECK RECEIVED BY ATE PERMIT'NO. <br /> I O AMOUNT DUE AMOUNT REMITTED <br /> . EH 13.24[REV.r/K , K/ <br /> EH 14-20 <br /> J74' <br />