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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <br /> i (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work berein 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 /> A_ld City Odrr- of Siz Acreage <br /> Job Address <br /> II r I��t_[ / Address - � Phone <br /> Owner's Name F <br /> �? '{� � <br /> Contractor E tffS cJ C 0�Address t+0I License fro. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT4L.]L, " DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> Ni- SYSTEM REPAIR ©~ - _ """ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 1- !E`WERL LINES DISPOSAL FLD. ^` PROP. LINE <br /> FOUNDATIONS_-, ' AGRICULT,URE'WELL OTHER WELL PITS/SUMPS t <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS <br /> Dia- of Wall Casing <br /> F) Industrial ❑ Open Bottom ❑ Manteca G Dia.•of Well Excavation ft <br /> FI Domestic/Private Cl Gravel Pack L1 Tracy Type of Casing_ Specifications <br /> I'I Public f-1 Other ' ' (l Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. .t--,. State Work Done <br /> Well Destruction ❑ Well Diameter ; Sealing;lfaterial &.Depth <br /> Depth Filler Material & Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONTW REPAt ADDITION I I DESTRUCTION I I allo septic system <br /> m permitted if public Sewar is <br /> r <br /> eetJ <br /> Installation will serve: Residence_ 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 ❑ Type/Mfg i Capacity No. Compartments ' <br /> _ x <br /> PKG. TREATMENT PLT. ❑ r Method of Dispo;el <br /> Distance to nearest: Well Foundation ' Property Line . <br /> LEACHING LINE C1No. & Length of lines Total-length/size <br /> FILTER BED F) Distance tor nea►ast: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS Af Depth ESire o?"X,ekoz I� �'' Number <br /> UM Cl Distance to%nearest: Well Foundation ' IC94- Property Line��" <br /> DISPOSAL PONDS ❑ <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 t <br /> Home owner or licensed agent's signature'oenifies 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 hiring or sud-contracting signature <br /> certifies the following: "I cariity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." ' <br /> The applicant mus call for all required inspections. Complete drawing on reverse side. �J <br /> Signed Title: Date: J/--Y <br /> FOR DEPARTMENT USE ONLY <br /> Applica ' n Accepted by ? �� - - -- Date Area Z <br /> I rout Ins tion by Date <br /> Final Inspection by Date -- —y <br /> I Additional Comments: <br />� ,f <br /> Applicant -Return all copies to:` San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> t . 445 N San Joaquin, F O Box 2009, 8tkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO 'l c��/ <br /> . EH 13.24 MEV,r/HSI f a� / " �� L /r/'�Z �=✓ b <br /> EH 14.26 -. <br /> r <br />