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SANI,jOAQUIN COUNTY PUBLIC HEALTH <br /> DI —3420` '. ENVIRONMENTAL PHONE (209)468-5420 <br /> X445 N SAN JOAQUINa,� . CA 95201 <br /> +, P 0 BOX 2009, STOCgTON, <br /> PERMIT EXPIRES L YEAR <br /> FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application la hereby trade to San Joaquin County <br /> for a permit to construct and/or install the vork herein described. Sans <br /> application is made in co®pliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Pules and Regulations <br /> p Public Health Services. <br /> Ir Joaquin County i ♦ t Size/Acreage <br /> .City _f <br /> Job Address <br /> 1 '1 Phone 'I <br /> " Address Q� tl X <br /> Owner's J � Phone <br /> 1 �License No. � <br /> l Address t of Service Well ❑ <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION <br /> NEW WELL ❑ OTHER ❑ Monitoring Well <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LIN1. ES —�--� OTHER WELL PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK -- AGRICL1t TUBE WELL _ <br /> FOUNDATION �.�-- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Man— tea Dia. of Well Excavation <br /> n Industrial Specifications <br /> ❑ Tracy. r Type of Casing— Type of Grout <br /> [1 Domestic/Private Cl Gravel Pack , f;. <br /> #:1 Other �T <br /> "" <br /> p naDelta, '° ^©eptri of Grout Seal !_ <br /> i'I Public fir._ -- -- 'SurfTce Seal Installed by �W►t <br /> t �I`ITirigation �-- Approx. Depth l I Eastern State Work Done <br /> H.P. <br /> Repair Work Done L3 �YPa of Pump {� <br /> 0/ , rf Sealing Material & Depth <br /> Well Destruction Well Diameter ^- <br /> Filler Material & Depth <br /> Depth <br /> �OF_agvailabla°within,200 feet.) <br /> hI,♦;REPAIR�AITION I iI,DEST N I I INo septic system permined if pubiicVsewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> Installation will serve: Residence Commercial '.t icier — € 1.1 <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to in depth of 3 leei:I 6apacity — - No Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> r� <br /> PKG. TREATMENT PLT.❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well ��..--� <br /> } °f Number <br /> SEEPAGE PITS I I Depth Site Property Line <br /> SUMPS — ���--- <br /> t <br /> LI Distance to nearest: Well Foundation { <br /> DISPOSAL PONDS ❑ <br /> � hend that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I ave prepared this application <br /> rules and regulations of the San Joaquin County g• work for <br /> Home owner or license u agentnnargas tOrbecome s the c°Ito workman'srtcompensation laws°of Caliloronia.e Contractor sthiring orthis es b cont acermit is e nglsignlature <br /> employ any per <br /> Car68 <br /> l t6, wirng: "I ca ify the[i a pert0a eof the work for which this permit is issued, f ahaH employ persons subject to workman s compention lawsola."The applia or r ui s. omplete drawing o e �ide. <br /> �f/ , <br /> Title: Date. <br /> i Signed X <br /> FOR DEPARTMENT USE ONLY a O2 <br /> - Date �~ ea-7. <br /> I Application Accepted by f <br /> Date�-- <br /> I Final Inspection by Data <br /> Pit or Grout Inspection by <br /> Additional Comms ter alth <br /> He <br /> Applicant - Return all copies tar Environmentaln Joaquin °untY HealthUblic Permit/Servicesv Services <br /> 1. 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 <br /> �. MOUNT DK RECEIVED BY D E PERM17'NO. <br /> FEE AtJE AMOUNT REMITTED <br /> INFO <br /> (/U <br /> ) EH 13•II iREv.iiNyiDc�� � 1. <br /> EH 14.26 f <br />