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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r3 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 i <br /> �4 P O BOX 2009, STOCKTON, CA 95201 <br />` PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made`F <br /> 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. J <br /> City Th Lot Size/Acreage <br /> Job Address /7L J <br /> 11 Q jj� f f Phone <br /> 4 <br /> �fY'+tt(��ip KE il/Ll2i� � 11 Address 4 ��` <br /> Owner's Name f <br /> Contractor Address <br /> j��f�; C License No. �(�' �� Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 <br /> OTHER ❑ Monitoring well C7 <br /> l &21h r a SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS o <br /> { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E, Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Tracy Type of Casing_ Specifications <br /> 11 Domestic/Private Gravel Pack /� /Public iJ <br /> •1 s Other fl Deka Depth of Grout Seal Type of Grout <br /> i <br /> Irrigation A9dO Approx. Depth I I Eastern Surface Seal Installed by ` <br /> H P State Work Done <br /> Repair Work Done L] Type of Pump Sealing Material & Depth <br /> I Well Destruction ❑ Well Diameter <br /> Filler Material & Depth <br /> Depth <br /> TYPE-6F—SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INailablseptic <br /> syst m emitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other - <br /> Number of living units: Number of bedrooms_ [� <br /> Water table.depth <br /> Character of soil to a depth of 3 feet:' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> a Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHINGINE ❑ No. & Length of lines Total length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> I SUMPS LI Distance to nearest: Well Foundation _ Property tine <br /> DISPOSAL PONDS ❑ <br /> ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <br /> rules and regulations of the San Joaquin-County <br /> d agent's signature certifies the following: <br /> Home owner or license "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ompensation laws of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's c <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 compenss- <br /> t tion laws of r Calif rnia." <br /> The applictfnt- st call for all require r pections. Complete drawing aP reverse a <br /> Signed Title: (/tet, Date: <br /> FO DEPART ENT U ONLY <br /> Application Accepted by <br /> Date �1 <br /> Date <br /> by <br /> Pit or,Grout Inspection by f y' '� Date "� Final Inspection by <br /> Additional Comments: <br /> Applicant - Return a 1 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 CA RECEIVED BY DATE PERM1 f'NO. <br /> ' INFO <br /> . EH 13-24 IREV.I/n 5! <br /> EH 74-2e <br />