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r <br /> SAN JOAQUIN COUNrPY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> �V PERMIT EXPIRES 1 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 co®pllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ServiCeB. <br /> City G� C Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address __ ` Phone <br /> Contractors.� _..�_-.;'l_[.-Address a �� cense Ne��PhonE <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION u Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'Qi OTHER ❑ Monitoring Well C7 ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> —.10 omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I') Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. De th I Eastern Surface Seal Installed by <br /> Repair Work Done _* Type of Pump H.P.. -� State Work Don �rp <br /> Well Destruction\CI Well Diameter Sealing Material & DepthIt;1 e <br /> r Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> J <br /> Installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: - Water table depth 1 <br /> SEPTIC TANK. r ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ $ "�. - ^ ' ""`'Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> • j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt `'"Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I 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 /> certifies the following: "I cartify 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." ] <br /> The applijeoff-m-011. call for all requircti s. Complete drawing,on a rse side. <br /> Signed X Title: Date: <br /> sr •, <br /> �DEPARTMEN7 USE ONLY i <br /> Application Accepted by Date 1 Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 4&u, <br /> Additional Comments: --- <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn-, CA 95201 <br /> FEE AMOUNT DUE AMO NT REMITTED CA k R FVED BY DA PERMIT NO. <br /> INFO <br /> • EH 11-24(REV.I/w 51 <br /> EH 1620 <br />