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SAN JOAQUIN COUNTY PUBI,i&2HEALTH SERVICES <br /> ENVIRONMENTAL ZEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> C 1tv: <br /> a. � ✓-' 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 trade 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 /> Job Address ( Lot Size/Acreage <br /> S- <br /> Owner's NamJ City <br /> i <br /> ��a f-`� <br /> Y,.,�p Address Phone <br /> �Contractor ' s v Addres 'Uelt License NO3_11?7�6_Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 7 <br /> PUMP INSTALLATION Q <br /> SYSTEM REPAIR hi. OTHER C1 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia- of Well Casing <br /> Cl Industrial 0 Open Bottom C3 Manteca <br /> Domestic/Private ❑ Gravel Pack+ El Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other C1 Delta Depth of Grout Seal Type of Grout <br /> Inigatian ____ Apprax. DI <br /> III th I I Eastern Surface Seal installed by I I e <br /> Repair Work Done ^ Type of Pump H.P. State Work Don a <br /> Well Destruction 0 Well Diameter <br /> Sealing terial 8 Depth <br /> � pepth,/ Filler Material & Depth <br /> TYPE`OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <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. ❑ }R' Method of Disposal , <br /> t Distance to nearest: Well Foundation Property Line l� <br /> r - <br /> LEACHING LINE 0 No. & Length of lines Total length/sire <br /> FILTER BED n Distance.to nearest: t Well Foundation i Property Line <br /> SEEPAGE PITS ifI DepthSiie ~' Number S/ <br /> SUMPS LI Distance to.nearest: Well J Foundation Property Line <br /> ' DISPOSAL PONDS ❑ L 1�- • ' .1e_ <br /> I hereby certify that I have ptepar`ed this application and that'th6 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,iignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ampioy 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 of Cal' <br /> The applica t must II for all requir spsctlon Complete drawing on rev side. F" <br /> Signed X Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> - -- <br /> Application Accepted by w.. Date ^ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/services <br /> f' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> fH 13-24[REV <br /> £H t4-Za <br />