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'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ` PERMIT R"TRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joe urn Count for (�3� 1 Q� r I <br /> q Y permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and <br /> Joaquin County <br /> the Rules and Regulations of San <br /> q'PPublyicc.Health Services. <br /> Job Address g S <br /> City Lot Size/Acreage <br /> rV <br /> { Owner's Name <br /> ` Address - Phone <br /> F e <br /> Contractor Address g <br /> License No, Phone? <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENT ❑ <br /> DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESC7 <br /> DISPOSAL FLIT, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t f 7 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation <br /> f-1 Domestic/Private Ll Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> Type of Casing._. Specifications <br /> 0 Public 1-1 Other k 1-1 Delta Depth of Grout Seal <br /> Irrigation A Type of Grout <br /> �._ pprox. Depth lI `astern Surf a Seal installed by <br /> Repair Work Done U Type of Pump PD,ftlo H p <br /> Well Destruction O Well Diameter Sealing Materiel & Depth State Work pone <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ! INo se tics stem <br /> P Y permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other_ Other available within 200 feet.) <br /> 1.� <br /> Number of living units:I Number of bedrooms ('(1 <br /> Character of soil to a depiq of 3 feet:. - <br /> SEPTIC TANK ❑ Type/Mfig Water table depth r� <br /> PKG. TREATMENT PLT.❑ Capacity— No. Compartments e r <br /> Distance to nearest; Well Method of Disposal I <br /> Foundation -��,. Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation Pro , <br /> Property Line <br /> SEEPAGE PITS ( I Depth Size <br /> SUMPSNumber <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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, an <br /> d <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 person in such manner i to become subject t1 workman's compensation laws of California." Contractors hiring or subcontracting signature <br /> certifies the following; "I certify that in the Performance of the work for which this Permit is issued, !shall employ tion laws of California." p p y persons subject to workman's Campansa- <br /> The applicant m all f II requ' ` inspections. Complete drawing onr vers de. <br /> Signed X <br /> Title: Date: <br /> `F R DEPARTMENT USE ONLY <br /> Application Accepted by 4�. „_ <br /> L7.xe�•1. ...._ Date Area_ <br /> Pit or Grout Inspection by § <br /> Date <br /> Final inspection by���,�,r-ri,,.7 Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMI ED CK <br /> INFO CASH RECEIVED BY DATE PERMI7'No. I <br />• EEm 14-20 <br /> H 1344 1REV.I/n 5y S <br />