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SAN( ;AQUIN COUNTY PUBLIC HEALTH. :RVICES <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 /> 11 (Complete in Triplicate) <br /> e <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z- 1 eor ��3 -- City Lot Size/Acreage <br /> owner's Name S N! Address Y ZZ/1 Xr' '4u L=. Phone <br /> 20 <br /> Contractor�SeS s 0*,1 T Address License No. 78� , Phone_ <br /> TYPE 0 <br /> P F WELL/PUMP: NEWWELL ❑ Cl <br /> WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L-3, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._ DISPOSAL FLD.,T PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL A. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `ff <br /> LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.:of Well Casing <br /> r-1 Domestic/Private CI Gravel Packl ❑ Tracy ,Type af'Casing Specifications <br /> I'i Public CI Other n Delta Depth of Grout Seal Type of"tt,,rout rn <br /> I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by ' J <br /> Repair Work Done U Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth 'Fille`r bWfii'ial A'Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) " <br /> Installation will serve: Residence Commercial— Oth'er <br /> Number of living units: Number of bedrooms--- a a <br /> Character of soil to a depth of 3 feet: J -'Water table depth ! <br /> SEPTIC TANK ❑ Type/M f •�a EffT <br /> ­'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distanc to,near t. II _- un a Io Property Line <br /> !c t <br /> have wit—ft <br /> LEACHING LINE 0 No. & Len� �h °o h�jes. �i �+ �r �r1C Total length/size <br /> FILTER BED ❑ Distance tb; s`teEngl,��prn �tSufidat��� ed Property Line — <br /> by r nitirnnm° e�-N � } +'inn - '`'•" <br /> SEEPAGE. PITS I I Depth i Size Number <br /> SUMPS L) Distance to nearest: Well Foundation Property Line <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 ordihances, state laws, and <br /> rules and regulations of the San Joaquin'County <br /> Home owner or licensed agent's signatureicertifies the following: "I certify that in the performance of the work for which this p=rrhit is isst#d, t shall not <br /> employ any person in such manner as to'b' come subject to workman's compensation laws of California." Contractor's hiking of sub-contracting signature <br /> canifies the following: "I certify that in theiperformance of the work for which this permit is issued, I shall employ persons subject to workmsn<s componsa-. <br /> tion laws of California." ri - <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. t <br /> Signed X Title: -C-10e ` A-Iiso� Date: / z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byW. <br /> Date I �Z— Are, <br /> Pit or Grout Inspection by Data Final Inspection by Date 1 <br /> �r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE � AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. <br /> INFO C� CASH <br /> . CH 13-24 MEV.I/M 5f � � 1 I`�' � � �. ♦� �'�/O ��? �Cl��[1 <br /> EH t4•26 <br /> I - \ <br />