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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �- <br /> �__�.-- - (-Complete in Triplicate <br /> Application in hereby made.to San Joaquin County for a permit to construct and/or install tYSe 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 Count Public Ffea �h Services. <br /> City Lot Size/Acreage `� ! <br /> Job Address <br /> SIC <br /> Owner's Name <br /> Address ~t Phone <br /> i <br /> L <br /> Address License No. � <br /> Contractor Phone <br /> ' <br /> TYPE Of WELL/ UMP: NEW WELL 71WELL REPLACEMENT Cl DESTRUCTION L1 Out of Service Well <br /> PUMP INSTALLATION 0SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS—.� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing j <br /> C:l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 11 Public 111Oche 11 Delta Depth of,Grout Seal ype of Grout <br /> ini{lation /Approx..Depth, I I Eastern Surface Seal Installed by <br /> AAI AiCA <br /> Repair Work Done 0 z Y;,of Pump+ H:P"—"" � S — State Work Done <br /> .� <br /> Well Destruction D Well'Diameter <br /> if —t�. Sealing-Matetial & Depth <br /> Depth ._ Filler Material &'Depth <br /> TYPE OF SEPTIC WORK:(*NEWT'NSTALL•ATION:I_1—REPAIR/ADDITION I-I DESTRUCTION l 11No 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 soil to a depth of 3 feet: E Wagr ► <br /> SEPTIC YANK. 0 Type/Mfg Capacity ; No <br /> pgra- <br /> PKG. TREATMENT PLT. ❑ �` Me s 424 <br /> Distance to nearest: Well Foundation Property <br /> LEACHING LINE ❑ No. & Length of lines Toiai Iength�bz� UG <br /> FILTER BED ❑ Distance to nearest: Well Foundation tl� lfidi� TAL l j �L <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> _ <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_ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work loo which this permit is issued, I shall not <br /> employ any pars n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signatu <br /> certifies the U wi�rg: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa <br /> tion laws f Ca nla." 1 r <br /> The ap A t st call for all rsg6 ed ins=bn . mplete drawing on raver ide. <br /> Signed Title: Date: r <br /> FOR DEPARTMEN USE ONLY r �T <br /> Application Accepted by Date 7� Area <br /> Pit or Grout Inspection bye Date Final Inspection by Date <br /> I <br /> Additional Comments: ± I <br />+ Applicant - Return all copies to: San Joaquin County Public Health�Servlces; <br /> Environmental HealthPermit/Services <br /> 445 N San Joaquin, P O Box 2009, fStkn, CA 95202 <br /> PEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13.24IREY,tiM5r <br /> 1010 <br /> EH 11-26 YY V <br />