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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N, SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam 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� j <br /> i <br /> �- f CitY����Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address Phone <br /> ���T �r`�as l� 7 License No <br /> Contractor � Address <br /> Phone �Zf <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION t Moli <br /> ervCe Well <br /> ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Elnng Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> I"i Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by ' <br /> Repair Work Done L] Type of Pump H.P: State Work Done <br /> Well Destruction s Well Diameter l <br /> kit Sealing Material & Depth C <br /> 7' Filler Material b Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.l = V <br /> Installation will serve: Residence_ Commercial_ Other �J <br /> Number of living units: Number of bedrooms I <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 Cl No. & Length of lines Total length/size <br /> FILTER BED F) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> � tt" <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line e ° <br /> DISPOSAL PONDS ❑ <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 1 <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; l;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-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is i963'ed,A shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must 11 for li requ ed inspections. Complete drawing on�reverseside.F <br /> Signed X I Title: ED G- -15pate: G -Z- <br /> 1 I <br /> K FO DEPARTMENT USE IONLY <br /> Application Accepted by ` € Date Area 6 .o <br /> Pit or Grout Inspection by <br /> .,.pate Final Indpection by Date t <br /> Additional Comments: <br /> j Applicant - Return all copies to: San Joaqui`n`Coun-ty-.Pubiic Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED i GK t RECEINEA,f3Y DATE PERMIT'NO. �v r <br /> CASH <br /> . EH1241REV.tinsi�,! 3� �0��` (� 052 <br /> 16 � <br /> EH t4-�•2a <br /> 1 <br />