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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 <br /> 4 <br /> PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> (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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> r�Health <br /> /Services. �n <br /> I Job Address �s`r-.3��1:��� � ^y City Lot Size/Acreage 'L_4 �G <br /> { i Owner's Nar4'6U4-e ZdOJA�A <br /> Address S+�'•` Phone <br /> (Contractor 1g! t% _(Xos- Address-�/ o *-�O�G�70 License No37731P`S Ph11s?34_y2t r <br /> -TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION,. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK S+� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IC1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- � Dia. of Weil Casing 6 <br /> : 4�,o <br /> Domestic/Private @'Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> V1 Public I'l Otl}ef , n Delta Depth of Grout Seal Type of Grout„ <br /> l ;i I Irrigation t &QL Appl(iix. Depth l I Eastern Surface Seal Installed by `Zo��GA� <br /> I:.Repair Work Done 0 Type o�Pump it--d H.P. ! State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material. & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Y Niim6ei iif'living:untts:" "� '�Number of hetlroomi�°� -'= '4 <br /> Character of ioi)to a depth of 3 feet: Water table depth }- <br /> SEPTIC TANK ❑ Type/Mfg ." °>•+ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f ray{ R:F.� Method of Disposal <br /> ✓r Distance to nearest: Well A' Foundation Property Line <br /> LEACHING LINE ❑ No. B Length of lines Tatal lenbth/size <br /> FILTER-DED ❑ Distance to nearest: Well _— Foundation .ti Property Line <br /> SEEP-SAGE PITS 11 Depth Sixes <br /> I — �..�.:tee.'„' r �".�._- --' <br /> SUMPS Cl 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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed adent's sigriature certifies the following:";A certify that in'the performance'of the work for which this permit is issued, I shall not <br /> employ any person in such manner asitc to ome.,subject-to-Workman's compensa.lio-n_laws-of California,"Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify Wat in`the performance of the.work-for-which this'`pirrpit isJssued,_l-ehall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant mus all f 'r'efl required inspections. Complete drawing ori reverse side. <br /> Signed ,Title: q&eA= ____ Date: G-fes X72. <br /> FOR DEPARTMENT USE ONLY <br /> I i <br /> 54 /• <br /> j Application Accepted by Date � – / Z Area <br /> Pit or Grout Inspection by ate –3 Z-Final Inspection by Date <br /> Additional Comments: !Owll, " l <br /> -Applicant.-. Return all copies'to: San Joaquin County Public Health vices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> t (FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY- DATE PERMIT'NO. <br /> NE <br /> IL <br /> Ek 13.21(REV:t/tr 51 /4V� . / "S , 7 W �"`y <br /> EH 14-M U•L <br /> f F .ti .+' - <br />