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' OAQUIN' COU TT PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL�HEALTH DIVISION 1 � , <br /> 445 'N''SAN 'JOAQUIN, PHONE (269)468-3420 <br /> P O BO% -2009, STOCKTON, CA 95201 <br /> j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> , w K• (Complete in Triplicate) <br /> 013,18 hereby trade to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> s;^; ! `'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.VY <br /> 3& <br /> ag <br /> Job Address , y._ Lot Size/Acre e <br /> Owner's Name i �_t �� A,ddrgss - _ Phone <br /> Contractor Address {{ 'cense No.43rPhone .. s� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION Gl Out of Service Well ❑ <br /> PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKSWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> CD Industrial ustrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> O <br /> r.I DOmes4ic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth l I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ti <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDIVONLjo-CESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Re 'dente LjCommercial Other <br /> Number of living 4units: Number Of bedrooms__ <br /> Character of soil to a depth of 31feet; �?4,s/ _ ___.—_Water table depth <br /> SEPTIC TANK ' ❑ Type:/Mfg Capaci�y No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE %a_- n. Length of lines Total length/size <br /> Fou <br /> FILTER BED 4 F] Distance to nearest: Well Foundationif PrOpertylinej r <br /> SEEPAGE PITS wo-6ept' Size Number <br /> SUMPS l L3 Distace to nearest: WeNFoundations_ Property <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that'i have prepared this application and that the ork 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 i<ignaturg,eectifies thea0110 ng: '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 sbject io_Workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in thepr,rformance of the work for which this permit is issued=I shall employ persons subject to workman's compensa- <br /> tion of California." <br /> The applica u call to ct ns. drawing an arse side. <br /> { t r <br /> Signe tie: _ Date: .. <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> wf. <br /> Application Accepted by *��- '��'"^aT"'"'� . Data i Area <br /> Pit or Grout Inspection by Date Final Inspection by ` G���' V Date ! /�- <br /> Additional Comments: <br /> _ Applicant - Return all copies to: San Joaquin County 'Public.'Health Services <br /> 't Environmental °Health Permit/Services <br /> - 945 N San Joaquin,\P O,Hox 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 N0. <br /> !Z <br /> I; ..x`EN t3.2i IREV.t r <br /> _� tck i/•2E ' <br />