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a <br /> U <br /> ' 6 <br /> s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sew 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 /> Job Address City Size/Acreage <br /> C <br /> Owner's Name Address (� Phone <br /> ContractorsL�L�4� aI Address License NoL�.�Phone <br /> *, <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION o out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR $4 OTHER ❑ Monitoring Well G7 <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 /> F1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 46 Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing_ Specifications 1 <br /> V1 Public is Other (-1 Delta Depth of Grout Seal Type of Grout <br /> I I Ifti inion —Approx. De lh� /I I Eastern Surface Seal Installed by (� <br /> RepairWorkDone X Type of Pump ,� r3.IC H.P. State Work Done O ' r <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I k DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feel.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms C <br /> Character of soil to a depth of 3 feet: Water table depth C <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Companments . <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ -Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 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: "I 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 ofZnThe a icant or all required ins lions. COmplete drawing on re ver si <br /> Signed X Title: Date: <br /> FORD _FITMENT USE ONLY y <br /> Appiic lon Accepted by (fes Date <br /> Pit or Grout Inspection by Date Final Inspection by Date 43 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N Ban Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED I CASH <br /> 0 RECEIVED BY DATTEE/ PERMIT'NO. <br /> INFO♦ EH 14.E IREV,t i w SI�! 1 / /�i G✓O� 1 <br />