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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445NSB% PHONE <br /> pO2009, STOC TON, CA95201(209)468-3420 <br /> PERMITIF <br /> EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made. San Joaquin County for a permit to construct Ordinance No. 59 and/orand insand theeRules anwork d Regulations dof San, <br /> is made in compliance xith San Joaquin Count <br /> Joaquin County Public Health 9ervic�s. 1Lot Size/Acreage 1 x <br /> o rM� City <br /> Job Address r h <br /> :,nelt. <br /> �JneAddress " � " /_Owner's Name RZ&wAddress License Ilo.��—Contract WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of erwell ❑ <br /> NEW WELL ❑ OTHER O Monitoring Well [� <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES � DISPOSAL FLD. PROP. LINE <br />- DISTANCE TO NEAREST: SEPTIC TANK � — AGiiICULTURE WELL OTHER WELL PITS/SUMPS � � <br /> FOUNDATION � . <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE — ;Dia�of,;_Well,Casing , <br /> # ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Industrial _ ;:. �Specilicatio s <br /> CJ Tracy Type of Casing_ � <br /> C.1 Domestic/Private <br /> ❑ Gravel Pack - TypeofGrout <br /> (:1 Other i-1 Delta Depth of Grout Seal '"¢ <br /> y ".i'1 PUbI1G .- <br /> I 1 irrigation <br /> Approx. Depth t I Eastorn�.�- Surlaca-Seal-installed-by .�may+ o <br /> H.P "' State Work'Oona ^, <br /> Repair Work Done 0 Type of Pump ��—� <br /> Sealing Material &;Depth <br /> Well Destruction O Weil Diameter <br /> ler M6terinl,i,-Depth ' <br /> Depth <br /> :�DESTflUC710N I 1 INo septic system permitted if public Sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I EPAIR ADDITION available within 200 faet,l <br /> f installation will serve: Residence Commercial Other <br /> Number of living units:_-,Number_af room Water»table depth <br /> '' .R a <br /> Character of soil to a depth of 3 fel+ No. Compartments f lQ <br /> Capacity _ <br /> SEPTIC TANK _*_TW"ig:` f � Method of Di9posal6 <br /> PKG. TREATMENT PLT. ❑ ( <br /> tl <br /> S� Foundation - Property Line - <br /> Distance-to nearest: Weil ; l�-J / A- <br /> A <br /> _ = <br /> i Total length/size' <br /> LEACHING LINE No. & Length of lines , �' Line-- <br /> ` U Foundation �T• Property — — <br /> FILTER BED <br /> ❑ Distance to nearest: Well.� rt e,- <br /> ' 1—Size Number : <br /> SEEPAGE P1T5 l I Depth Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS '. ❑ <br /> s application and that the work wi11 be done in accordance with San Joaquin county ordinances, state laws, <br /> I hereby certify that I have prepared thiand <br /> rules and regulations of the San Jaquin County g work for <br /> l not <br /> Home owner or licensed aagent's n^signature tobecomfies the e subject lto w+orkmen'srtcompensat on laewaoof Celiforniahe Contactor srhiring othis r sub-contracting ermit is issued, lsignlaturre <br /> employ any porno <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ parsons subect to workman s compen <br /> tion laws of California." <br /> The applicant m call for al re ire inspections. Complete drawing on reverse si <br /> Title: Date: <br /> Signed X <br /> J FOR DEPARTMENT USE ONLY <br /> Date. 3`1 1'-�3- Area <br /> Application Accepted 4 } ' 3 3 <br /> I Final Inspection by w Data <br /> Pit or Grout Inspection by t Date — <br /> I <br /> Additional Comments: <br /> les to: County Public vices <br /> Applicant - Return all copEnvironmental Healthpermit/Servvices <br /> ' 4 445 N San Joaquin, P O Box 2009, Stkn, .CA 95201 <br /> CK FRECEIVED $Y DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASN <br /> INFO 0 3 Co <br /> . Lj <br /> EH 13-211REV.r/+rsf <br /> i Ell 74.25 <br />