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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> I ENVIRONMENTAL HEALTH DIVISION ' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ^„t I P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 /> J_J <br /> Job Address �� City Lot Size/Acreage <br /> t <br /> ne�sff Na rens Phone 1 ; <br /> C I f 2&24e ssor L ' License No, Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN D DESTRUCTION Cl Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE r TYPE OF WAW PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> X <br /> dustrial © Open Haltom r❑ MantecaDia. of Well Excavation Dia. of Well Casing <br /> tioCaliastic/Private C)`Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ublic El Other `I n Delta Depth at Grout-Seal ' # Type of Grout <br /> I I trriUation ..Approx. Dept l I sternf 5urfaoe;Seal,lristall6d�by_ <br /> Repair Work Done Type of Pump H.P` Z State Work <br /> Well Destruction /❑ Well Diameter Sealing Mate3rial`& D'ep'th # A +_ _ 11s/ <br /> ogDepth Filler Material 5 Depths 3 i ✓ 1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic .system permitted if pub c sewer is <br /> I I available within 200 feet.) <br /> Installation will serve: Resir once_ Commercial— Other <br /> Number of living units: Number of bedrooms .� <br /> Character of soil to a depth_of 3 feet: Water table depth <br /> SEPTIC TANK. Cl ,Typo/Mig I Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ll f f 3 Method of Disposal <br /> I' D'I+stance.to nearest: Well Foundation Property Lite -• <br /> LEACHING LINE ❑ Length#of lines `. Total length/.size r r <br /> FILTER BED ❑ distance ta_'naarest;,....Wel1- - �Feundation.`; Property'Line <br /> SEEPAGE PITS 11 ~Depth Size M1 Number <br /> SUMPS El Distance'to�earest: Well Foundation i. 3f Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this apphcation and that the work will be done`in accordance with fan Joaquin county or&nankes, state laws, and <br /> rules and regulations of the San Joaquin County <br /> l Home owner or licensed agent's signature certifies the following;"I•certhy that in the performance of tfta work for which this p mit is issued, I shall not <br /> employ any parson in such manner as to becorne subject to wrirkmBn's�pmpagEation.lawa of Caiiforni9;. Contractor's hiring or sub-contracting signature <br /> 'I <br /> certifies the following: certify t at;in the peWo-imance of the work for which this permit is issued;J shall ploy persons subject to workman's compensa- <br /> tion laws of California." <br /> 4 T ♦� `w u' <br /> The applica t call for el fired i pectiona. omplete drawing on re se side. <br /> Si ne Thl Date; <br /> OR rm ENT USE ONLY a�. <br /> G t <br /> Application Accepted by Date __�V" r-{ 2'� 1 Area �y <br /> Pit or Grout Inspection by Date Final Inspection byCZ <br /> ' Date Q <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 0 Sox 2009, 8tkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE ( AMOUNT REMITTED (CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.241REV.riNs1tO-Z;i 2 <br /> EH 11.26 <br /> �"/ ✓ <br />