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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES K� 7 7d <br /> j ENVIRONMENTAL HEALTH DIVISION /moo <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 -Iwo <br /> 209)468-3420 �o <br /> '1 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 blit Health V Services. � <br /> Job Address IA , l ! -yx ID. } _ Cityatk) Lot Size/Acreage <br /> ..Owner I a Name Left 1 L&Address :s_ a r 1 e J „_. ...,., Phone gsa-40 <br /> M, tTacto� "`� Add I �1 �'o0, 0- icense No. Phone { <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 7 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SVI MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> dZustrial 0.Open-Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n <br /> omestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> f'1 Public CI Other n Delta Depth of Grout Seal Type of Grout <br /> RepairWorkln ^_Approx. Dept , I I astern j- - _Surface Seal Installed by <br /> Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Q Well Diameter 6,1 Sealing Material & Depth ��� <br /> Depth ) �` y -Filler Material h Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted if'public sewer is <br /> - - a_v_ailable_within_200 <br /> feet.I,1 <br /> Installation will serve: Residence Commercial_ Other - 1 <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to s depth of 3 feet: - w .W,ei table depth - <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments A- <br /> PKG. TREATMENT PLT.C] ? <br /> t _ Method of;Disposal <br /> Distance to nearest: Well Foundation Property Line ; <br /> { h <br /> LEACHING LINE 0 No. & Length of lines Total length/size y I <br /> FILTER BED ❑ Distance ti� nearest: Well Foundation- -------Property-Line-3 <br /> SEEPAGE PITS I I Depth * Size, Number 1 <br /> t <br /> SUMPS CI Distance t -nearest: WeIP Foundation— Property Line .... <br /> DISPOSAL PONDS O <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 eignature 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 California Contractor's hiritig,*sub-contracting signature <br /> certifies the following: "!certify that in the performance_of thi.work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." %.J , <br /> The applica "usstt calPI <br /> r all required inspections. Complete dra lng on verse ' <br /> Signed Title: Date: <br /> s FOR DEPARTMENT USE ONLY Q '1 <br /> Application Accepted by - Date v � 2` Area d cc <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies !to. San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE [[ AM NT REMITTED K RECEIVED BY E PERMIT'NO, <br /> .. EM 13-74{REV.rintil�� r(yr-y <br /> EH <br /> 14•70 / v �I/ <br />