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SAN_„JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) , <br /> r <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+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> / City Af"(Wp Lot Size/Acreage <br /> Job Address !/ <br /> Phone <br /> Address <br /> Owner's Name 3 . <br /> L� Address License No. Phone <br /> Gont+actor _ t <br /> TYPE 4F WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well L <br /> ,, PUMP NEW <br /> CS SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK4 SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C•1 Industrial` ❑-Open Bottom © Manteca Dia. of Well Excavation <br /> Type of Casing.- Specifications' <br /> (a Domestic/Private 0 Gravel Pack L1 Tracy Type of Grout \`. <br /> I'l Public L1 Other I. C 1 Delta Depth of Grout Seal ` <br /> i <br /> Approx. Depth 1 I Eastern Surface Seal Installed by <br /> ii Irrigation <br /> Repair Work Done 0 Type of Pump' H.P. State Work bane — <br /> ”" Sealing Material ii Depth <br /> WeII Destruction ❑ Well Diameter . <br /> Depth iL Filler Material,& Depth <br /> TYPE OF SEPTIC WORK: NEW iNSTAILLATION i I REPAIR/;AODITIO DESTRUCTIO I INo septic system:permiued�if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenceL Gommerciat� Other - s <br /> Number of living units: -t- � )Number-of bedrooms I r <br /> Character of soil to i depth`of 3 feet: <br /> Water.tattle_depth <br /> SEPTIC TANK ❑ Type/Mfg f Capacity_. Na. Compartments <br /> PKG. TREATMENT PLT. ❑ i( rr -A= l T —Method ofMisposal <br /> Distance t �o nearest: Well Foundation y Z., Pe6peity Line <br /> t <br /> r <br /> r <br /> LEACHING LINE CI No. & Length of lines Tota1-langth/size- _ <br /> a �T Foundation �-_ bQ <br /> Property Line <br /> FILTER BED n Distance toi nearest: WeII -A * r <br /> SEEPAGE PITS ry, L I Depth T Size ' NNumber. <br /> Distance tti nearest: Well Foundation,�T- Property Line ' <br /> _ SUSUMPSWlF Alj Q lovl <br /> DISPOSAL PONDS ❑ 1 <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 l CountyI { <br /> Home owner or licensed agent's signature certifies the following: '!I certify that in the performance bf•the_work for which this permit is issued, shall not <br /> ! employ any person in such manner as to become subject to workman's compensation laws of California" Contractor's hiring or sub-contracting signature <br /> j 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 California." r <br /> f The applicant must call for al equir inspections. Complete drawing on reverse side. : <br /> fes_ <br /> Signed Date:Title:" _ <br /> DEPA E SE.ONLV <br /> ` Application Accepted by i Date Ar <br /> �l Pit or'f3rout Inspection by Date F!nall Inspection by Date <br /> Additional.Comments: <br /> I Applicant'- Return all copies .�to' San Joagu'in County Public Health Services <br /> r Environmental ronmntal Health Permit/Services <br /> T --FEE-_ <br /> — FEE - CK dECEIVELI BZY D TE NO. <br /> -FEE-INFO AMO ED66E AMOUNTREMITTED �J(� <br /> . EN 13.24[REV,I/nsl ( r / r � <br /> EN 74.26 CJI <br />