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- <br /> 1�. <br /> SAN JOAQUIN'COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �Q P 0 BOX 2009, STOCKTON, CA 95201 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;I (Complete in Triplicate) <br /> Applis madebincoompliance vith San county <br /> Joaquin Counr a ty ordirmit nanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe. <br /> Rules andherein <br /> Regulations of SanThis <br /> application <br /> Joaquin County Public Health Services. <br /> ee. 3m GC.rE <br /> /t City hot Size/Acreage <br /> Job Address 11 <br /> �-X .12 <br /> LV 1 Phone O�`�� d7 <br /> Owner's Name Address <br /> i 1^ Address t d�` a License.No6 Z�3 Phone <br /> Contractor �, [ O£STRUCTION LJ Out of Service WellLl <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT G7 Monitoring Well <br /> �SY'STEM-REP-AIR_L7_.___.,i -O.T,HER O�. �� <br /> PtdMP-INSTACLATION�� t .� -�--�----• . <br /> f ,.DISPOSAL.FLD PROP..LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ° Pt7SISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIfICATIONS Dia. 01 Well Casing <br /> Cl Industrial ,' Open Bottom 0 Manteca Dia. of Well Excavation <br /> T e.of Casin 5 e� Specifications <br /> Domestic/_Private ❑ Gravel Pack ❑ Tracy yp g Type.orout <br /> I I'I Public t. i n DeltaDepth of Grout Seal <br /> ff 't,� r x. Oe h I Eastern �' F—Surface Seal installed by R <br /> } I i irrigation <br /> `I Repair Work Done U Type of,Pump H.P. f- a State Work Done <br /> —'� Sealing Material i-Depth <br /> Well Destruction ❑ Well Diameter- Filler Material & Depth <br /> Depth , <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I V DESTRUCTION I I aFvailabpticle ihit m rented it public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: —L Number of bedrooms 7h <br /> Water table depth <br /> r Character of soil to a depth of 3 feet:` <br /> SEPTIC TANK El9 <br /> Type/Mf Capacity No. Compartments <br /> Method of Disposal <br /> f <br /> ' <br /> PKG. TREATMENT PLT. Cl <br /> t 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation [ Property Line <br /> t i <br /> SEEPAGE PITS 11 Depth Size `Number <br /> SUMPS El- Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CJ <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 /> empioy 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 certify that in the performance of the work for which this permit is issued, I shall.empioy pejsons subject to workman's compensa- <br /> tion Iowa of California." ' f <br /> The applicant mot call for all rqquire4 inspections. Complete drawing on reverse side, <br /> Signed <br /> Title: �- s •Date: <br /> FO DEPARTMENT USE ONLY�� <br /> Date ' zJl l� i — Area 2'-1 2- <br /> I <br /> I Applica[ion Accepted by ��.� }} <br /> Pit Gaut nspectian Da a �f anal Inspection by Datev <br /> Additional Comments: <br /> f Applicant - Return all copies to: San J uin County Public Health Services <br /> Environmental Health Permit/Services <br /> f 445 N San Joaquin P 0 Box 2009, Stkn, CA 95201 r <br /> 1 FEECK RECEIVED BY 4�q PEAM1T'NO. <br /> INFO AI1MOUNTDUE• AMOUNT R ITTED �ylf� I <br /> EM 13-24ISEV,r/K51 <br /> EM 14-20 ff <br /> k <br />