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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> p �ERMIT 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 to herebcmade nHealthiServiceah San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> ance v <br /> Joaquin county _ <br /> Lot Size/Acreage <br /> Job Address CY 4&-01701 2 y F 0- ✓ <br /> Phone <br /> Owner's Name � � �ss <br /> a <br /> Contractor ` h Address <br /> License Nn —phone a'6) <br /> WELL REPLACEMENT n DES7RLfC710N C} Out of Service Well C1 <br /> NEW ELL © OTHER ❑ Monitoring Well ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIRD1°SOA <br /> PUMP INSTALLATION D 'T-._ ' AFL"D.'-"� ".•-PRO?!UNE' i" <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ^---�— pITSlSUMPS <br /> FOUNDATION �..�-.� AGRICULTURE WELL OTHER WELL + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bo ©Manteca Dia. of Well Excavation <br /> Bottom + <br /> ❑ Industrial L] Tracy Type of Casing_ Specifications <br /> C7 Domestic/Private Ll Gravel Pack Depth of Grout Seal Type of Grout <br /> e f l Other n Delta i <br /> I'I Public ns <br /> Surface Seai installed by <br /> I I Irrigation __ Approx. Depth i I Eastern �a'1C <br /> H•P. State Work Done <br /> Type of Pump — <br /> S v � <br /> Repair Work Done Sealing_f4aterial-�_Aepth-----------•— <br /> Well Destruction ❑ Well Dia16_d ar_i__ Filler Material & Depth <br /> Depth t <br />� rrt TYPE OF SEPTIC WOflK; NEW 1NS7ALLATION I I REPAIRlADDiTION I V DESTRUCTION 4 I availablewithin <br /> ed w thin 200 feetc system .) �f public sewer.is <br /> l <br /> installation will serve: Residence! Commercial_ Other <br /> Number of living units: Number of bedrooms t <br /> € 4 1Wates labia depth - <br />' Character of soil to a depth of 3 feet: ` Capacity ---- No. Compartments, <br /> s:• <br /> SEPTIC TANK ❑ TYpelMfg' Method of Disposs3 ' <br /> PKG.'TREATMENT PLT. ❑ t Foundation Property Line �--- j <br /> Distance to nearest: Well 1 <br /> Total length/size <br /> of <br /> nearest.LEACHING LINE C-) No. & Length arest: Well --lines Foundation Property Line t { <br /> FILTER BED ❑ Distance to <br /> f - <br /> SEEPAGE PITS 11 Depth Sire Number _ <br /> SUMPS LI Distance to_nearest: Well- - <br /> _Foundation._:._ ----Propel Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work{�ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> shall not <br /> rules and regulations of the San Joaquin`County <br /> Homthis permit is issued, <br /> e owner or�ne need a m is signer to becomes the follobject wing: <br /> wing: "I cert compensation I. hat in the la soof California." Contractor's rhiring or sub-contracting lsignature._ <br /> employ any Pe <br /> certifies the following: "I certify that in the performance of the work for.,w�which this4peYmit�fs�ssued, 4 shall employ persona subject to workman's compensa- <br /> tion taws of California." <br /> The applicant must call for all requi inspections, Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> Signe f , <br /> DepAAX&ILENT USE ONLY <br /> rZ �� <br /> Date _ Area <br /> Application Accepted by <br /> ---- <br /> te. 4! <br /> Pit or Grout Inspection byD <br /> . ..- -- ateFinsl,lnspection by• <br /> ! � <br /> Additional Comments: r <br /> y <br /> Applicant - Return all copies to: EnvironmentalJoaquin oHealth unty uServices <br /> Permit/ServiceQ <br /> Ik 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> /'� <br /> . EH 13-21 IREV.r/n w V _ <br /> EH t4-2a 1 <br />