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t ... <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 3 0 <br /> ` <br /> : P O BOX 2009, STOCKTON, CA 95201 "1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS-SUED i <br /> (Complete in Triplicate) <br /> I.Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. is <br /> spplication 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 /> ^ "7 Gity L2Lot Size/Acreage y <br /> Joh Address f L <br /> Owner's Name Address <br /> �7.: /r O��C IE-41,_ Phone <br /> TV-Vey <br /> Contractor r S. �C.PAddress <br /> 'AAA � icense No.. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPIA EMENT i i DESTRUCTION ❑ Out of Service Wellgg ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well ❑ <br /> SEWER LINES— DISPOSALmFLD. PROP. LINE. <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br />-�-_ " -" TYPE OF WEL LPROSLEM AREACONSTRUCTION SPECIFICATIONS <br /> INTENDED USE' Dia. of Well Casing <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing- Specifications <br /> f7 <br /> Domestic/Private ❑ Gravel Pack L`Tracy T yp 9- Type of Grout3 <br /> I'i Public Cl Other Cl Delta Depth of Grout Seal <br /> i I irrigation �_Approx. Depth i I Eastern Surface Seal installed by p" ,_t <br /> of Pump H.P. 7 — State Work Done <br /> Repair Work Done LAY Type Sealing Material Depth l U <br /> Well Destruction ❑ Well Diameter hiller Material & Depth VV <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR lADDITION l I DESTRUCTION I I afvailableseptic <br /> w thin 200 feetited it public sower is <br /> i <br /> I <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: — 2' <br /> SEPTIC TANKS D TypelMfg Capacity No. cpA*#AENT <br /> 4. Methcf� W J <br /> PKG. TREATMENT PLT. Cl Rai.»» <br /> Distance to nearest: Well foundation Property Line_*y U - _M93 <br /> Total fengthlsiz �`(( ��]] �� C0kJN I �[ <br /> LEACHING LINE L� No. 8 Length of lines �pLTH_ (�{I <br /> FILTER BED 0 Distance to nearest: Wall Foundation Proper N Oq D�VISI�N Ufa <br /> MEI_TmTh <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> .-:DISPOSAL-PONDS_ ❑ _;:.: -- �, c <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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." <br /> The applicant t call for all required�insppeections. Complete drawing on reverse side. <br /> Signed X ��'�` .s:"' — Title: Date: <br /> g <br /> DEP TIME US NLY <br /> Dat:�"Application Accepted by AreaDate <br /> Pit or Grout Inspection by Date Final Inspection b <br /> t <br /> Additional Comments: <br /> es to: San Joaquin County Public Health Services <br /> Applicant - Return all copi <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCA RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EM 13.211REV.linst 7 '�f-O Q 749 do <br /> EH 14.25 <br />