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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 /> 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 vork 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. <br /> Job Address 06CityLat Size/Acreage .— <br /> Owner's Name Address Phone <br /> Contractor ss r License No, Phone l <br /> LI <br /> TYPE Of WE L/PU NEW W d WELL REPLACEMENT 1� DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR C7 OTHER ❑ Monitoring Well <br /> DISTANPE 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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other C1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. -State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material A-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 9 REPAIR/ADDITION I I DESTRUCTION I I lNoBNailable septtic sy t m permfa mated if public sewer is <br /> Installation will serve: Residence! Commercial_ Other <br /> Number of living units: _/_ Number-of bedrooms A <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TAMC_ ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal I <br /> Distance to nearest: Well l hCl Foundation _rD Property Line I � �F <br /> LEACHING LINE ❑ No. & Length of lines __�3 -C - -_ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> qUMPS <br /> EEPAGE PI 11 Depth y Size Number / <br /> Ll Distance to nearest: wellJ 6T Foundation !ZJ2 Property line h� <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 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 patten 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 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 taws of California." <br /> The applica ust for 1 pections. Ca 19 rawing on reverse side. .^ <br /> 1� <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> A licatlon Accepted by r^ Date Area <br /> P or Grout Inspection by Date Final Inspection by at ez <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 RECEIVED BY DATE <br /> CASH I ERMIT'NO. <br /> INFO SH .p <br /> . EH 13-241REV,rin5r7 <br /> EH 14-26 / LL <br />