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r _ <br /> r <br /> 1 ✓" t <br /> ..SAN JOAQUIN COUNTY P013LIC HEALTH SERVICES <br /> t�+Y1G ENVIRONMENTAL HEALTH DIVISION <br /> r� [j 445 N SAN JOAQUIN, ?HONE (209)468-3420 <br /> P O BOX 2009,. STOCKTON, CA 95201 I <br /> 10- Q � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � (Complete iri Triplicate) <br /> VOIApplication is hereby made,to San Joaquin County' for a permit to construct and/or install the work herein described. This <br /> application is made 1n 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- `' 'yot Size/Acreage <br /> Address �J .. r'1 f .�3 _ Phones <br /> Owner's Name L_ r <br /> /. 'Address c / L � hone <br /> Licgnse NoContractor ! l � <br /> TYPE OF WELL/PUMP: NEW WELL 7WELL REPLACEMENT( DESTRUCTION O Out of Service Well <br /> PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER O Monitoring Well `L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40 DISPOSAL FLD; PROP. LINE <br /> FOUNDATION 3c 1 AGRICULTURE WELL L OTHER WELL J'O.I— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS <br /> C..l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio - IL Dia. of Well Casing i <br /> Tx,Domestic/Private Gravel Pack ❑ Tracy Type of Casing__ Specifications _ <br /> I'I Public 1:1 Other fI Delta Depth of Grout Seal __� ' I Type Grout <br /> I I Irrigation Approx. rl <br /> Depth/ I I Easterfq Suri ce Seal Installed by / % <br /> �iepair Work Done Type of Pump. 7 . ``�> .+`/>.f�.P. / �` State Work Done �' �p <br /> Well Destruction Well Diameter _ _ Sealing terial & Depth <br /> lox <br /> Depth 20 � Filler Material & 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total langth/size _ <br /> FILTER BED 1:1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size t — Number <br /> SUMPS LI 'Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> 1 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: "1 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-contragting 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 /> 1 tion laws of Colifornla." <br /> i The applicant must dill for all requir d inspections. Complete drawing on revere 1de. v <br /> Signed �' �, ,.'.•, ti.�_"Tltle: ( f '7�J1 i�l� l`y� Date: <br /> t R D ARTMENT USE ONLY <br /> Application Accepted by - Date Area <br /> Pit or Grout Inspection by Date�'J inal Inspection by_ W Data �Z L <br /> Additional Comments: / <br /> Applicant - Return all copies t . San Joaquin County Public health Services <br /> Environmental Healt'h:4ermit/Services 1 <br /> 445 N San Joaquin, P`O Box 2009, Stkn, CA 95201 <br /> FEE NFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH ECEIVED BY DATE "PERMII'NO. <br /> �� <br /> C7 <br /> EH 1324IREV.r/$5, ;c r <br /> EH 14'26 <br /> 1-7/ fl <br />