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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 ;E <br /> PERMIT EMPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Applicis hereby <br /> incompliance xithuin SanCounty Joaquin Counr a tyrmit to Ordinancen[toruct 5u9Batzdo1862atall snd theeRules and <br /> Regulations dof Sans <br /> application <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage h l n n — <br /> Job Address <br /> Phone <br /> Owner's Name H o w a r d A r n a i Address <br /> ContractorG <br /> l a r k Well <br /> Address License No. Q.—Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well 0 <br /> OTHE Monitoring Well L7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 Test R c <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _ DISPOSAL i=LD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 600 ft t e S t Well <br /> f] Industrial © Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing <br /> 1� _ I <br /> Specifications i <br /> (-.1Type of Casing_l Domestic I Private ❑ Gravel Pack 0 Tracy Type of Grout <br /> I'i Public [:I Other n Delta Depth of Grout Seal <br /> l <br /> I I irrigation Approx. Depth 11 Eastern Surface Seat Installed by d <br /> p of Pump H.P. State Work Done <br /> Repair Work Done L] Typo Sealing Material & Depth <br /> Wel! Destruction ❑ Weil Diameter ----6-u_— r <br /> Depth Filler Material & Depth <br /> em 130(m <br /> TYPE Of SEPTIC WOflK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION I I (Noavaseptic sy t 200 feet.) rl public sewer is <br /> n <br /> Installation will serve: Residence_ Commercial..— Other <br /> Number of living units: �' Number of bedrooms Water table depth <br /> Character of soil to a depth of:3 feet: <br /> . Capacity Na. Compartments <br /> SEPTIC TANK0 Type/Mfg <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> I rules and regulations of the San Joaquin County <br /> t Home owner or licensed agent's 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 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 o1 California.' <br /> The applicant f i on a plate drawing on reverse side. <br /> Signed <br /> Title: Dale: <br /> I R FITMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> _6 <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ate <br /> Additional Comments: rr OG <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> :EAMZOUNTCK RECEIVED BY DATE PERMIT'NO. <br /> i <br /> DtlE AMOUNT REMITTED CASHEH 13.24IREV.I/ v 0Ae!e C�;, , <br /> EH 11.20 <br /> trJ D Cfw•o d <br /> ;ten _ <br />