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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 /> J# (Complete in Triplicate) <br /> Application is hereby made to San iJoaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cornpliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services ) A� <br /> City Lot Size/Acreage <br /> Joh Address <br /> Address � T Phone <br /> Owner's Namel <br /> ��/ �,� icense No. Phone l <br /> Address <br /> TYPE OF WELL/� PUMP: NEW WELLS WELL REPLACEMENT C1,i` DESTRUCTION ❑ 't of <br /> Well <br /> PUMP INSTALLATION SYSTEM REPAIR l OTHER ❑ <br /> - -tom - <br /> DISTANCE TO NEAREST: SEPTIC TANK-,,-_- EWER LINES = t DISPOSAL FLD, PROP, LINE <br /> FOUNDATION 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 Q w <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Type of Grout - <br /> i. Specifications <br /> V <br /> i'1 Public (i Other Cl Delta depth of Grout Seal �! <br /> I I irrigation _.Approx.+De th i I Eastern, Surface Saul Installed by _ <br /> /11�/Q�/ State Work Done <br /> Repair Work Done 0 Type of Pump -- TAS <br /> °t�� Sealing Material A Depth <br /> Well Destruction ❑ Weil Diameter <br /> 2„pd Filler Material S Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sew at is <br /> f available within 200 feet.] <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms ENT <br /> Character of soil to a depth of 3 feet: W"" '-ble <br /> SEPTIC TANK 13Type/Mfg Capacity No ,�n . <br /> PKG. TREATMENT PLT. O ( Me,Flo(�Dpp�B <br /> r <br /> Distance to nearest: Well Foundation Propert <br /> gLi f"3�Y <br /> s_N�bA F_s <br /> V�Jr�S nL lo E- {,0' ' . <br /> C1Total Is <br /> LEACHING LINE No. &'Length of lines � <br /> FILTER BED, ❑ Distance to nearest. Well Foundation ropeny Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> hDISPOSAL PONDS ❑ 1 <br /> I 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 /> It rules and regulations of the Sen 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-contracting signature <br /> certifies the followingI Certify that in tha performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa- <br /> tion laws of Calit la. ' / <br /> Ifk Tha applicant st II for a117d ' ;ti Complete drawing on reverse side. <br /> Signed X Title: 41, Date: <br /> Date SE ONLY �? <br /> �' ` Area ` -- <br /> Application Accepted by , <br /> Pit or Grout inspection by .` Date Final Inspection by Date <br /> I Additional Comments: ' <br /> 1 ' <br /> ' Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> IFEE NFO AMOUNT DUE+ AMOUNT REMITTED ASH R CEIVED BY DATE PERMIT'N0. <br /> I <br /> i <br /> . EH -211REV.riKss <br /> 14 <br /> EM 11.20 <br /> J <br />