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r <br /> `k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,,k-PHONE (209)468-3420 <br /> III[ to P O BO%-2009,r.-STOCKTON, CA 95201 <br /> I • 4 � <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I (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 oempliance:vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />! Joaquin County Public Health Services. �� <br /> Job Address _ ' " " a<����K ��i CityS6CN_�t Size/Acreage <br /> i` <br /> Owner's Name �sf SQ�Q `�� Address Phone <br /> Contractor rL�Vtre, ! s Addres:-4!qp 7,t ID X 111.7 License No.11373 Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 / DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR $Y OTHER ❑ Monitoring Well <br /> :Y 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 Ind atrial O Open Bottom ❑ Manteca,,.,.�,w" Dia. of_Weil Excavation Dia. of Well Casing <br /> [.]?Imlestic/Private ❑ Gravel Pack l L7 Tracy Type of Casing_ m Specifications <br /> I'1 Public fa Other ! fl Delta I Depth of Grout Seal Type of Grout <br /> I I Irrigation _/ Approx. Dept i Eastern i Su ace Seal Installed by C If <br /> Repair Work Done Ui' Type of Pump " H.P. _ State-Work Done e <br /> Well Destruction ❑ Well Diameter SealingAftterial-&-Depth... .•: fpr <br /> Depth Filler Material 8 Deptkik"`� ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION i"I"'DESTRUCTION l 1 (No septic system permitted if pubfiesewer is <br /> ­available within 200 feet.) <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: .- ~a <br /> q _, y - -Water-table.depth � <br /> SEPTIC TANK ❑ e/Mf i <br /> T <br /> �Yp g y`�' r'-'�rf,.8pacity_-- Nti Compartments � q <br /> PKG. TREATMENT PLT. Cl >f Method of Disposal <br /> Di-stance to nearest: Well ;Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines N Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line tt <br /> i� <br /> SEEPAGE PITS 11 Depth f Size Number a <br /> SUMPS C! Distance torest: Well Fou anon Property Line <br /> DISPOSAL PONDS ❑ t r <br /> I hereby certify that ! 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 comity that in the performance of the work for which this permit is issued, I shall not <br /> employ any p n In h manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th ollowing: "I crtifV that in the porformanor-67 the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f Califs ia." <br /> The appy ant m t all req re m to drawing an6 Lwdo. <br /> IF <br /> 100000 <br /> Date: <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY M ? <br /> Application Accepted by Date �'-1 Area d �---+ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: f <br /> Applicant - Return all eopieslto: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 1: 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNTRREEMITTED K RECEIVED BY TE PERMIT N0. <br /> Ehr13.2 (REV.r i it 51 -7� l[� 57 <br /> EH 13.25 <br />