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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I� 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) <br /> a <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> II <br /> Job Address r3`= u� `�OVI� /YIA.U1 C4 ­ City Lot Size/Acreage <br /> .. t <br /> Owner's Name,,0%14L _ Address Q:3t19da%�Gr4 "Phone <br /> I <br /> If <br /> A _ I� <br /> Contractor 44f <br /> _ _UL6C,e Address es?� / /YiQOp License Phone ofk <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [ <br /> [_] <br /> Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications <br /> F] Public i 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation j —Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work pone L3 Type of Pump -,:H-P. . - State Work Done <br /> Well Destruction Cl Well Diameter SealfneMaterial &`Depth I <br /> I Depth II Filler Material 5 Depth { <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION'[) REPAIR/ADDIVONK DESTRUCTION I I INo septic system permitted if public sewer is 1 <br /> Il available within 200 feet.l <br /> Installation will serve: Residence jL Commercial_ Other <br /> Number of Wing units: Number of bedrooms ' ` <br /> Character of'soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ;I Method of Disposal <br /> Ditt$nce-tonearest:_T-Well' <br /> ,aTWell:` -Foundation.—_Property Line <br /> S <br /> LEACHING LINE ❑ No.~ Length of lines I Total length/size �. <br /> FILTER BED n Distance to nearest. f Well -Foundation Property Line r. <br /> SEEPAGE PITS l I Dept'k ` Size 1 Number <br /> SUMPS <br /> �r Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ s� _.- <br /> I hereby certify that I have prepared this application),and that the work will 6e done in accordancewwitlt San Joaquin county ordinances, state.laws,and <br /> rules and regulations of the San Joaquin County ; s <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, l shall-not, <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contrctp►,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 employ persons suubbjecf to workman's compensa- <br /> tion laws of California." I <br /> The applicant mus <br /> t call foj artr wired i spections. Complete dra g on reverse side. i f' <br /> Signed'�_ � Title; i f Date: � <br /> FOR DEP ENT SE ONLY <br /> 3 Application Accepted by Date a -�.V Ar aZ 1 -ti <br /> a ./a <br /> L Pit or Grout Inspection by II Date' Final Inspection by Data d4 �� <br /> o y <br /> Additional Comments: <br /> Appiic.ant' Return all- copies to Ban Joaquin County Pubic-Health Services <br /> Environmental Health Permit/Services <br /> 445,N-San-Joaquin.-P ().Box-2009—Stkn CA-95201'"" — <br /> FEE <br /> IN MOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE,f PERMIT NO. <br /> H 14-20 <br /> . k /� / II <br /> . EM 13.21(REV.1 i n 5) <br /> - <br /> I <br />