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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN .JOAQUINS;�,PHONE (209)468-3420 <br /> P 0 BOX'2009; -STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ~` <br /> (Complete in "triplicate) <br /> i <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 eoup1lance frith Be. 'Joaquin County Ordinance No. III and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address • �� City �r' ""• ize/Acreage <br /> Owner's Name ZZA� Address Phone <br /> ?o o k 1412o.7 <br /> bl L 373 S�i66 L 6 <br /> Conlraclor ul-, . Address 141 Z 7 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION 0 Out of service Well ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y?. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION{; AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation pia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I') Public CI Other fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation / .Approx. Depth I I�East rn Surf et eel Installed by _ <br /> Repair Work Dane Tl Type of Pump ��L7 H.P. 'L- State Work Done `A <br /> Well Destruction ❑ Well Diameter f ' sealing Material & Depth ___= <br /> �— ;• f.: <br /> ....�•- r- ..Depth. r _i-Filler Meterlal'A.ep�h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted ik,public sewer is <br /> i available within 200 feet,) <br /> Installation will serve: Resident Commercial_i'Other <br /> Number of living units: Nu 'r bedrooms <br /> Character of soil to a depth of 3 feet: sir �' /—Water table depth ' <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments - y-- <br />` PKG. TREATMENT PLT. C] � Method of Disposal <br /> k Distance to nearest:— ail Found on Property Line <br /> t �C 4 . <br /> LEACHING LINE ❑ No. & length of lines Total length/size <br /> FILTER BED [_i Distance to nearest: Well, Foundatr Property Line <br /> SEEPAGE PITS II Depth * Si:e Nu <br /> SUMPS L! Distance to nearest: We Foundation Pro Line <br /> DISPOSAL PONDS Q i <br /> I hereby certify that I have prepared this applicatiorVd 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 licennt'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 perso i such nner as to become sub' t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fo wing: "I cert' that in th7,,erfor c of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifor Is." 1 i <br /> The appli nt m f all r C plate drawing onr de. 0.011. <br /> Signed X Title: Date: • <br /> FOR DEPARTMENT USE ONLY ; <br /> Application Accepted by Date Area a Z 1 <br /> Pit or Grout Inspection by 'f Date Final Inspection by- Dat <br /> Additional Comments: ! <br /> i Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin Box 2009, Stkn, CA 95201 <br /> IF O AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY D E PERMIT'NO. <br /> r��j <br /> + EM tLZs 13-24(REV. n 5) r C7-0I l L/ /✓ (JX <br /> �� � <br />