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E <br /> f <br /> i 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 /> E <br /> - I.ERMIT EXPIRES .1 YEAR FROM DATE ISSUED <br /> {i (Complete in Triplicate) <br /> Application is hereby made.to SanlJoaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliancewith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health fSeervices. <br /> Job Address rte- City - Q� Lot Size/Acreage.2e A ,4 <br /> Owner's <br /> Name <br /> J��� Address — <br /> Phone <br /> Contractor a�5 ' Address n 3 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT !-i DESTRUCTION b 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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS./SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic I Private 0 Gravel Pack; 171 Tracy Type of Casing_ Specifications <br /> I'I Public f:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth t I Eastern. Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump P. State Work Done _ <br /> Well Destruction C) Well Diameter :Sealing Material b Depth t ' <br /> F <br /> Depth � 'Filler Material & Depth <br /> 4 ISI <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 , REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 fest.I r <br /> Ir Installation will serve: Residence Commercial Other .1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I �-- - s Water table depth <br /> SEPTIC TANK J*e T .e- <br /> ypelMfg � � Capacity No. Compartments 4 <br /> PKG. TREATMENT PLT:❑ : ' Method of Disposal <br /> Distaric'e to, <br /> .ynearest: Well Foundation Property Line <br /> t LEACHING LINENo:& Lengih of lines �_" br Total length/size <br /> f FILTER BED n Distance toy nearest. Well- t _Foundation. ) ..Property Line. 0 f <br /> SEEPAGE PITS !Depth �' size Number <br /> i SUMPS LI Distance to nearest: well oD Foundation /b Property Line <br /> f DISPOSAL PONDS 0 <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.work man's,compensation-law -s of Cont ractor's.hiring or sub-contracting signature <br /> certifies the following: "I certify that in the pafiormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> The applicant m all for all r d in spe ions. Complete drawing on reverse si b. <br /> Signed X i Title: Date; <br /> �- � A3SZ- <br /> s <br /> i F R DEPARTMENT USE ONLY <br /> 10 Application Accepted by ' Date Z Area f <br /> Pit or Grout Inspection b 1• - '�� ,Date Final Inspection by VoL. Date <br /> Additional Comments: I115I�Cfi>a Lr _� �i7 � ���d++• <br /> r AppXicant - Return all copies to: San Joaquin County Public Health Services <br /> 3 ` Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DA'T`EQJ�./� �jPERMIT'NO. <br /> . EH1 -211REY.r�„51 ��� t �®(� ��� / 1 � <br /> EH 114.2a 7 <br />