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SAN(PjAQUIN COUNTY PUBLIC HEALTH, I ' <br /> L­ ENVIRONMENTAL HEALTH DIVISION 1 <br /> i 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 NOW.& <br /> e <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in 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 /> Joaquin County public Health Services. <br /> YJob Address �4,1, City Lot Size/Acreage <br /> I Owner's Name Oitell V1 4!5 - �✓!0 Address �y�1 40/� Ir I <br /> �✓� .E/24 Phone <br /> Contractor Address \' <br /> /// License No. Phone <br /> TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Cl <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR C7 . -OTHER C3 Monitoring Well C� <br /> I DISTANCE TO NEAREST: SEPI IC TANK A SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I M Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack7 El Tracy Type of Casing_ Specifications <br /> 1'i Public I-1 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irritation _'Approx. Depth I I Eastern Surface Seal Installed by <br /> F <br /> Repair Work Done U Type:I of Pump H.P. State Work Done <br /> Well Destruction ❑ Well IDiameter SealingMaterial & Depth <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I OESTRUCTIONXI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 1 Commercial Other <br /> Number of living units: MP Number of.bedrooms " <br /> Character of soil to a depth of 3 feet: - Water//// Water table depth <br /> SEPTIC TANK ❑ T I/Mfg r No. Compartments <br /> PKG, TREATMENT PLT. 0 4_- !"' Method of Disposal <br /> - Distance to nearest:ped IBES u tion Property Line <br /> I� I ill aq-ha��� dire w� OU <br /> LEACHING LINE Cl No. b Length of liWJ0_r - eEnQ C0MQ1PtPd pr iTl&p ftte*gth/size <br /> FILTER BED ❑ Dilwtance to nearest:by [wNi _L t„p>idatit� Property Line <br /> ! f t IGd IO <br /> SEEPAGE PITS [ I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS ❑ 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 shah not <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: "l 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." �I� <br /> The applicant st call for all require inspections. Complete drawing on reverse side. r <br /> Sign e¢ ' Title: Date: -1 a d'c) <br /> ,07 <br /> �I FO DEPARTMENT USE ONLY <br /> Application Accepted by off', <br /> Date Area (211 <br /> Pit or Grout Inspection b <br /> pe Y II� Date Final Inspection by Date <br /> i .- <br /> Additional Comments: <br /> a <br /> Applicant -- Return alli copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> �. 445 N Sart Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT" E AMOUNT REMITTED 5H RECEIVED 13Y DATE PEFIM17'No. <br /> r� <br /> EH 14-21 CA EV. /N5� if <br /> EH 112a r 'l C <br />