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SAN JOAQUIN COUNTY PBSL•IC HEALTH SERVICES a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON', CA 95201 <br /> per L c PERMIT EXPIRES 1 YEARFROM DATE ISSUED <br /> (Complete in Triplicate) <br /> here made to San Joaquin County for a permit to construct and/or install the work herein described. This � <br /> Application is by <br /> ith Ban Joaquin County Ordina ce No. 51+9 and 1862 and the Rules and Regulations of an <br /> application is made in compliance w <br /> Joaquin County Public Health Services. <br /> jl0 City Cr Lot Size/Acreage # <br /> Job Address f <br /> Owner's Name • e Address ' <br /> License IV Phone <br /> Contractor Address <br /> TYPE Of WELtlPUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> t OTHER ❑ Monitoring Well <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK PITS/SUMPS <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '_ <br /> D'industrial i �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 4� f <br /> I Type of Casing_ Specifications <br /> Domestic/Private ❑ Gravel Pack C7 Tracy Type of Grout <br /> r 11-i <br /> I•I Public Cl Other n Delta depth of Grout Seal <br /> I i irri anon ___Approx. Da h I I Eastern urface Seal Installed by G <br /> g State Work Don <br /> Repair Work Dane Type of Pump H,P•, <br /> a $ealing'MsteYfal k Depth <br /> Weil..Destruclion ❑ Well-Diameter <br /> Filler Material & Depth <br /> t Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIAD0ITION I 1 DESTRUCTION I i a ailable1c system within 200 (eetitled if public sewer is <br /> Installation will serve; ResidenceR -Commercial— Other <br /> � off - <br /> NumberYof liviJunits:- Number of bedrooms Water table depth <br /> 'Character of soli to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK I ❑ Type/Mfg Capacity <br /> TREATMENT PLT. ❑ Method of Disposal <br /> PKG. ' <br /> Distance , — <br /> to nearest: Well Foundation <br /> property <br /> Line <br /> { -,Total length/size <br /> LEACHING LINE ❑ No. & Length of lines - - Property Line <br /> FILTER BED ❑ Distance to nearest: Well _� Foundation <br /> Number <br /> SEEPAGE PITS N { I Depth Size <br /> SUMPS �: LI Distance to nearest: Well Foundation ter' <br /> - Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Y 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 /> � t� ... «, <br /> Home owner or licensed agent's signature certifies the following: "l certify thain 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 CaI ornia." 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 COU <br /> The ap ant must call r all required i ons. mplete drawing on raver . <br /> Title: Date: <br /> Signed X <br /> n FOR EPARTMENT USE ONLY 1� <br /> fl \d _ Date �4 rea <br /> Application Accepted by <br /> �iDete� �— <br /> t Pit or Grout Inspection by Date Final Inspection b <br /> f Additional Cam�l nts: <br /> ` Applicant Return all copies to: San Joaquin County Public Health Services <br /> E! Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> JECK RECEIVED BY D E PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED toEH 13.24tREV. ,EH 14.25 <br /> r. - - <br />