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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �f1 (Complete in Triplicate) <br /> de to San Joa4uin County an <br /> for a permit to construct and/or install the work herein described. This <br /> Application is hereby rltacompliance with San Joaquin County Or <br /> No. 549 and 1862 and the Rules d Regulations of San <br /> application is made in <br /> Joaquin County Public Health Services. <br /> Ve_ ® City Lot Size/Acreage L l <br /> Job Address f69 L T11 <br /> Phone <br /> CJS �V Address <br /> Owner's Name 'ff '`j ' ; <br /> �' 2 �{ ['License tic. O `C phone J 3 <br /> Contractor-�� Address <br /> NEW WELL ❑ WELL RE ACEMENT Cl DESTRUCTION C] Out of Service dell ❑ <br /> TYPE OF WELL/PUMP: Monitoring,Ne11, ❑ <br /> ,SYSTEM REPAIR C7/ OTHER "❑ <br /> t� . ,,,PUMPS INSTALLATION ❑ DISPOSAL*FLD. PROP. LINE ' <br /> V' SEWER LINES �--- <br /> DISTANCE TO NEAR T:-SEPTIC TANK.�� PITS/SUMPS _ <br /> i FOUNDATION �-�- AGRICULTURE WELL OTHER WELL—� � r <br /> IJ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "Dia..of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> f7 Industrial Type of Casing_ specifications.-. 1 <br /> [,I Domestic/Private ❑ Gravel Pack n Tracy r Type of Grout r �� <br /> ! I-1 Other{-" � "❑ Delta Depth'of Grout Seal l!" <br /> i'1 Public'` i. �" l <br /> Approx. Depth I I Eastern -Surface Saul Installed by <br /> I 1 irrigation "" ' '�­—State Work Done' <br /> of Pump H.P. <br /> Repair Work Done LZ Type Sealing Material & Depth <br /> 'Well Destruction 0 Well Diameter �— Filler Material 6 Depth My <br /> Depth rr-_ _ <br /> TYPE OF SEPTIC <br /> WOR K: NEW INSTALLATION I I REPAIR,/ADDITION <br /> DESTRUCTION- I aNailas. <br /> blelrw Thin 20c SYSIBM 0 feat�t`ed it public sewer is" ' <br /> 1' I Commercial_ Other ---- i <br /> installation will serve: Residence _ ._ ,. I t <br /> Number of living'units: "Number of bedroo s - t <br /> ^ t Water table depth '' <br /> Character of soil to a depth of 3 feet + No. Companments <br /> f Capacity._ — <br /> SEPTIC TANK , r ❑ Type/Mfg <br /> t„ Method of Disposal { Q <br /> PKG. TREATMENT PLT.:CI Foundation/ Property <br /> Distance ta:nearest: Well r a <br /> Total length/size-1—a- � <br /> ' k, EACHING LINE ,❑ No. & Lerigtfi of lines <br /> Foundation Property Line <br /> FILTER BED r CI Distance to nearest: Well j.- <br /> t + L 1 f <br /> f� I lY Depth Size Number �---- <br /> SEEPAGE PITS ' <br /> Foundation Property Lina <br /> SUMPS, Ll.'Distance to nearest: Well q <br /> DISPOSAL PONDS` ❑ <br /> I .w L hereby certify than have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws. and <br /> rulesand regulations of the San Joaquin County <br /> l 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 /> s of <br /> employ any person in such a that in the perfobecomrmance <br /> o1 he work fogwfi ch this permit is sation i/a issued�f i shall employ persons rnia," Contractor's 'subj sring ubject to workman's gompensa <br /> certifies the'fo to" g <br /> � tion laws of California." 1 <br /> { The a plicant s all requi a spa s. C late drawing'on. <br /> n reverse side. a � <br /> p �-` � Date: <br /> itle: <br /> r Signed <br /> '" """ rOR PAATMENT USE ONLY <br /> _ - Date Area <br /> Application Accepted by z <br /> Date <br /> Pit or Grout inspection by Date_ - <br /> Final inspection by <br /> I <br /> j Additional Comments: <br /> Applicant - Return alb; copies to: San Joaquin County Public Health Services <br /> ;r Environmental Health Permit2Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> ;FEE: AMOUNT DUE AMOUNT REMITTED ASH <br /> _ n <br /> I> . EH 13.24{REV.t <br /> �"EH 14.20 <br />