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SANUIN COUNTY PUBLIC HEALTH IMICES <br />*VIRONMENTAL HEALTH DIVISI <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 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. (%,, �p <br />Job Address 1 , 31% cam, CDI�'Q�L �W ""AQ City '4r Lot Size/Acreage 45 <br />.- J.4, -M 4,VU t nJ COOXIt r e-OrVOFC HOU.0%,-J G.4-6.rDPer[d. <br />Owner's Name Pu811 CJW0 a Pt°f- Address I b1D E. /4^7_sLrp" AV& -7 V,6 Phone 4(,Pg"40(vG <br />Osrcxecec k_ ? /1% <br />Contractor ��r `Addres 3 t(/��' Alr Od�S/� License No. �frflG�G9 Rhone <br />TY—PE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />fl Domestic/ Private O Gravel Pack O Tracy Type of Casing__ Specifications <br />I'1 Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br />1 I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by <br />Repair Work Done U Type of Pump H. P. State Work Done <br />Well Destruction O Well Diameter Selling Material ti Depth <br />Depth Filler Material 6 Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br />Available within 200 feet.{ <br />Installation will serve: Residence — Commercial _ Other <br />Number of living units: Number of bedrooms <br />Character of son to a depth of 3 feet: Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity No.RCafh <br />PKG. TREATMENT PLT. 0 Me <br />Distance to nettrest: Well Foundation Property l'l� j(tp e 2 <br />LEACHING LINE 0 No. 6 Length of lines Total lengthf;i"JOA UIN COUNTY <br />FILTER BED Cl Distance to nesiest: Well Foundation EN I ILHT1CC1�' 1 n1V1 ;11P`l <br />SEEPAGE PITS 11 Depth Si:e Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS O <br />1: .91 <br />Rx <br />I hereby certify that I have prepared this applic'Ation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and V <br />rules and regulations of the San Joaquin Couk4 <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 workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies the following: 1 certify 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 o4 iifornls. <br />The at licant m st II" for r „ jD pections. Complete drawing bn <br />c verse side. <br />� <br />igned dTitle: T • Date: <br />eOR DEPARTMENT USE ONLY <br />Application Accepted by AData %J 19 2, Area <br />Pit or Grout Inspection by _ _ Date Final Inspection by Date <br />Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N Salt Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br />. EM 13.241REV. r/h5� <br />EH 14.25 <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK, <br />RECEIVED BY <br />DATE PERMIT' NO. <br />DINFO <br />L.� <br />�t ,�",'� <br />(� <br />