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_ i I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N6 W <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 /> (Complete in Triplicate) f a It, P-, <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein S be i&d I"f41 <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re�t��'of San <br /> Joaquin County Public Health Services. <br /> Job AddressP <br /> _ 1 " City •sf'�AJ Lot Size/Acreage <br /> Owner's Name hldf� /��e AddressY.6 •� Phone <br /> s <br /> Contractor 0 WAL-lei Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cil DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION j AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom% ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack C ❑ Tracy Type of Casing_ Specifications <br /> 1'I Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter `� Sealing Material & Depth <br /> Depth r Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITiON.I I DESTRUCTION 91Nff iNo septic system permitted if public sewer is <br /> available within 200 feet.) I <br /> Installation will serve: Residence_ Commercial_ Other `' I <br /> Number of living units: Number of bedrooms r~ X" <br /> Character of soil to a depth of 3 feet: Water table depth nn <br /> SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments h) <br /> PKG. TREATMENT PLT. ❑ f ` Method of Disposal <br /> We <br /> Distance to nearest: i`c WellFoundation # -` Property Line <br /> LEACHING LINE ❑ No. & Lengthof lines Total length/size <br /> FILTER BED n 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 Cl :I <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 it <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 of California." <br /> The applicant mut call for all required i spections. Complete drawing on reverse side. <br /> X`Signed X r Title: elfDate:ry <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by �� _, Date Areal S <br /> t G� r <br /> Pit or Grout Inspection by 1 Date j Final Inspection by 5' �:Sp /] Date <br /> Additional Comments: �,�LL�S_L 1Qt 7 �i le6 k-� AV L r <br /> P _ - ...,._.� <br /> Applicant - Return all copies'`to: San Joaquin County Public Health Services <br /> I+I+ Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE CK Of <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> _ , <br /> . EH13-24{AEY.iin51 �e{l �O�] fd� �.I� 5r+��Z Ci <br /> EH i{•2a 47�/ <br /> 3 <br />