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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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. s <br /> application is made in compiiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.O� f� eye9�y` Lot Sine/Acreage <br /> City��----� <br /> Job Address <br />�- Phone <br /> Owner's Name 742 Cr 7 Address <br /> Contractor AV Address <br /> LV v <{� License No. Phone <br /> a�! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D <br /> OTHER D Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _.�.---- DISPOSAL FLD. PROP. LINE <br /> e FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> `INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing {� <br /> I [.-] Industrial ❑ Open Bottom ❑ Manteca Diad-ot Well Excavation 9m <br /> [.1 <br /> 7ypa of Casing_ Specifications— <br /> C3 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Grout r� <br /> F1 Public Cl Other fl Delta Depth c f Grout Seal <br /> I I Irrigation —Approx. Depth l I Eastern Surfaca Seal Installed by <br /> of Pump H.P. State Work Done <br /> Repair Work Done U TYf� Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION l I availableseptic Thin m peermiitted if public sewer is <br /> r - Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: AeirA� 7. i C <br /> i AIM C1,621: A-C L Capacity o No. Compartments <br /> SEPTIC TANK 0' Typo/Mfg <br /> F PKG. TREATMENT PLT. Cl + Method of Disposal <br /> -'r. Foundation Property Line <br /> Distance to nearest: Well `� � Y <br /> i <br /> LEACHING LINE Qf No. & Length of lines 3 �a Total length/size <br /> FILTER BED ❑ Distance to nearest: well <br /> '00 Foundation a.!r Property Line <br /> I 4 <br /> SEEPAGE PITS 11 Depth ~` Size Number. <br /> SUMPS ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <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 /> employ any person in such manner as to become subject to workman's compensation laws of Calif6rriii." Contractor's hiring of sub-contracting signature <br /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's comp ensa <br /> c <br /> tion laws of California." <br /> The applicant mus cell for all required inspections, Complete drawing on reverse side. I <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by r t <br /> Pit or Grout Inspection by <br /> Date - Final Inspection by ate <br /> s <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 O Box 2009, Stkn, CA 95201 r� <br /> FEE K R EIVED BY D E PERMIT�NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> EE <br /> F . EH 13.24 IREV.1/n 51 <br /> EH 11.2E <br /> s <br /> f 4 - <br />