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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ���• 445 N SAN JOAQU1N,,.P•H0NE (209)468-3420 <br /> P O BOX 2000' ` sTOCgTON CA 95201 <br /> .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F (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. 51+4 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health'ServiceB. <br /> Job Address �T,�1 A Led`L/ City _ • Lot Size/Acreage <br /> Owner's Name�+ 1 Address Phone'` <br /> oZContractor 1 _ Address /y 3+-3 Phone �+ <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT C] DESTRUCTION 0 Dut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Z _ OTHER ❑ Monitoring Well E� <br /> r <br /> Di.SxANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> `} Z FOUNDATION 'AGRICULTURE WELL OTHER WELL —PITS/SUMPS . <br /> s; ,(NY MUD USE -TYPE OF WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS r <br /> - -. 5 Industrial . .O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ` Ca Domestic/Private't ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta -- Depth of Grout Seal -''"� Type of Grout i <br /> I I Irrigation A =.Approx. Depth "`I I Eastern Su ce Sedi Installadby , <br /> Repair Work Done e<Type of Pump I j ¢'f`s H.P. � State Work Dona G <br /> i S �t � <br /> Well Destruction O %Well Diameter , ealing Materia] &-D' th <br /> Depth "__-�Filler Material-&`-Depth <br /> - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA'IFI/A DIYION I I DESTRUCTION IYI INo septic system permitted if public sewer is <br /> ` ! y available within 200 feet.) 1 <br /> Installation will serve: Residence_ Commercial t'Other rmo >' <br /> Number of living units: ? Numb of bedrooms <br /> Character of soil to a depth of 3 feet: -"" Water table depth <br /> t. <br /> ASEPTIC TANK C Type/M,fg Capacity No. Compartments <br /> PKG. TREATMENT PLT Cl I Method of Disposal <br /> '. Distance tonearest: II Foundation Property Line <br /> _ ` <br /> LEACHING LINE ' :Cl No.A Length of lines Total length/size <br /> -FILTER BED Cl Distance ta,nearest: W Foundation Property Line <br /> tv x. 7 <br /> SEEPAGE PITS L 1 Depth `r ct Size Number <br /> SUMPS LI Distance to neares : Well Foundati Property Line , <br /> DISPOSAL PONDS O <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, and <br /> rules and regulations of the San Joaquin County'1,.r.4; <br /> Home owner ant's signature certifies'ihe following; "I certify that in the'periormance of the work for which this permit is issued, I shall no <br /> employ an arson in such nner as,to becorfie sub to workman's compensation laws of California." Contractor's Erring or sub-contractin lure <br /> eertifisa s tollowing:-. c ify,that in the rfor.' c f the work for which this permit is issued, I shall employ persons subject to workman's camp <br /> tion la s of Calif nia." <br /> The-' "pita for al a uir <br /> q � rts.:• rowing on side <br /> it <br /> Sign )d� '�: %sr` Title: '� Date: t <br /> FOR DEPARTMENT USE ONLY <br /> �p ! t <br /> Application Accepted by �h�tte6`! i#"�'"• .*-�.AM�41 IY:1�Y1,- Date�� _ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z 2 <br /> Additional Comments. / <br /> t ` . <br /> Applicant - Saturn all copies to; San Joaquin Cejunty Public Health Services o <br /> Bnvironmental.Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, ,Stkn, 95201 <br /> ' FEE AMOUNT DUE AMOUNT REMITTED RECEIVED eY DATE PERMIT NO, tf <br /> INFO YCAA<—L_- <br /> . EM 1314 1lIEV,1ia+51 �Q J <br /> L C t Dz) , t <br /> 'EH it•Ta 1� '[ <br />