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I <br /> �l <br /> 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 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 /> Ui <br /> Job Address _ ��rP 7 y ,C _ ��V 1. � City*Ar Lot Size/Acreage <br /> I � y� <br /> Owner's Name _r!f(f��A �� IC[�C- Address 1i•{ Phone �� 4 <br /> Contractor Afp l Jh ° Address P_a&Qt�s 31306 314- License No. Phone . .J6 <br /> TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMPi;pINSTALLATION O SYSTEM REPAIR ❑ OTHER p Monitoring Ne11 C7 <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 /> n Industrial ❑ Open Bottom © Manteca pia. of Well"Ex6&V4ti6n"- Dia:of Well Ca ng <br /> (l Domestic/Private Cl{Gravel Pack O Tracy Type of Casing- Specifications <br /> I') Public .1 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —,Approx. Depth.- I i Eastern Surface Seal Installed by <br /> Repair Work Done C] Type of Pump H.P. ' State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth IM Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW.INS ALLATlON I I REPAIR/ADDITION I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> i( available within 200 feet.) <br /> Installation will serve: Residence -Commercial T Other <br /> Number of living units: �I`iNumber of bedrooms v <br /> Character of soil to a depth of 3 feet: i <br /> Water table depth <br /> SEPTIC TANK �Y Type W <br /> /Mfg —_ XfLc71&z_ Capacity L-l� No. Compartments <br /> PKC. TREATMENT PLT. ❑ I r. Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line n <br /> LEACHING LINE i+ No.!'& Length`of lines Total length/size <br /> FILTER BED n- Distiini a to nearest., Well <br /> SO Foundation ^�o� Property Line <br /> SEEPAGE PITS 11 Depth —- -8 _ Size vC ��� Number <br /> SUMPS .av Distance to nearest: Well SA"-vl- Foundation >T..e *'0- 'Pioperty Line . /6 <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 /> 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 she not <br /> employ any person in such manner as to become subject to workman's compensation 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 of California." �� r <br /> The applicant rl call for all r iced inspections. Complete drawing on reverse side. T <br /> Signed X Title: Date: - 9 L 1 <br /> r 2�=_ <br /> SE ONLY <br /> Q <br /> Application Accepted by Date - * �1 R Area <br /> Pit or Grout Inspection by 11 Date Final Inspection - - Date D �� <br /> Additional Comments: <br /> I � t <br /> Applicant Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK 9 <br /> t <br /> FFEE <br /> FOAMOUNT DUE AMOUNt REMITTED CASH 'RECEIVED BY DATE PERMIT'NO. <br /> + EH 1REV.t/n SI <br /> EH i4•Ta +1 a �,�r 7N9 -- <br />