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v <br /> - AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Ce ` �� ENVIRONMENTAL HEALTH DIVISION { <br /> 445N SAN JOAQUIN, ?HONE (209)468-3420 <br /> tel` f P 0 BOX 2009, STOCKTON, CA 95201 I <br /> 1 <br /> � <br /> q0- PERMITEXPIRES 1 YEAR FROM DATE ISSUED . <br /> li Q �e'�' l (Complete iri 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> f Joaquin County Public Health Services. <br /> Job Address City-J� ,, <br /> �1oc Size/Acreage <br /> i <br /> F `l I l Address Phony <br /> Owner's Name / - --+ <br /> yr ,/ !TY C. JJ ✓ l � 4 �Licf'n <br /> Contraslor se No. Jri �{'hane <br /> f `'" Address <br /> TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT DESTRUCTION O Out of Service Well <br /> PUMP INSTAL LATIO SYSTEM REPAIR O OTHER O Monitoring Well [7 <br /> �y .. c: . r t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . .. . DISPOSAL FLD. PROP. LINE FOUNDATION 3f i AGRICULTURE WELL OTHER WELL PITS/SUMPS .r <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom O Manteca Dia. of Well Excavatio �i Dia. of Well Casin <br /> __ <br /> rjd <br /> Domestic/Private �Gravel Pack ❑ Tracy Type of CasingSpecitications <br /> 'I'I Public f.l Other n Delta Depth of Grout Seal - I Type Grout !"3. <br /> I I Irrigation __.Approx. Depth/ I I Easter� Surf ee Seal Installed by :1 + <br /> Repair Work Done Type of Pump. �% `'/ .�`1 J//�f.P. State Work Done <br /> Well Destruction Well Diameter Sealing terisl & Depth <br /> Depth �?b �J Filler Material 6 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 /> j Number of living units: Number of bedrooms <br /> Character of soil to a depth of.3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity... No. Compartments <br /> i PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines, Total length/size—__ <br /> FILTER BED Cf Distance to nearest: Well Foundation Property Line <br /> 4 - <br /> SEEPAGE PITS 11 Depth Size — Number <br /> SUMPS LI Distance to nearest: Well Foundation Properly Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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-contrapting signatwe <br /> it 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 of California." <br /> the applicant must Wil for all requk d inspections. Complete drawing on/reeverge Ade , / <br /> Signed l C 6� '-----Title: l L f 7�� ft Gt:y"1 Date: , / /15 � <br /> R DYSPARTMENT USE ONLY <br /> Application Accepted by - Date } � �~ "� Area /.r __ <br /> IT <br /> Pit or Grout Inspection by Date�/linal Inspection by_ �`' Date _Z— 2_ <br /> Additional Comments: 7� <br /> Applicant - Return all copies t San Joaquin County Public Health Services J <br /> Environmental Health°Permit/Services 1 <br /> 445 N San Joaquin, P"O Box 2009, Stkn, CA 95201 <br /> FEE NFO AMOUNT DUE AMOUNT REMITTED CASHCK If ECEIVED BY DATE PERMIT NO. _ <br /> . EH 13.24 IREV.1+ns1 �f Dv /ry <br /> EH 14.26 - / <br /> lJ,.G' .-I H <br />