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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESa <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 � <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> quin county for a permit to construct and/or install the work herein described. This <br /> Application is hereby made to San Joa <br /> ance No. 5G9 <br /> application is made incompliance with San Joaquin County Ordin ,.and 1862 and the Rales and Regulations of San <br /> Joao H <br /> Lot Size/Acreage <br /> City <br /> Job Address _ / 7� <br /> �jIM, 14'z� Phone i� <br /> Owner's Name �Q�" Gf9'"gl�� Address <br /> pp '�Cy . �.�a Phone `. <br /> Address License No _._�.�--- <br /> Contractor pESTRUCTION ❑ put of Service Well 0 <br /> TYPE OF WELQPUMP. NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well Li <br /> ' INSTALLATION ❑ E <br /> SYSTEM REPAIR Qi" OTHER ❑ <br /> PUMP I <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES �— -- PITS/SUMPS <br /> FOUNDATION'— <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing_ <br /> 'Domestic/Private ❑ Gravel Pack7 C1 Tracy Depth of Grout Seal Type of Grout <br /> I'I Public (-I Other !1 Delta Q) <br /> I ! Irrigation �.Approx. Depth I I Eastern Surface Seal Instalied by <br /> T <br /> H P State Work Done <br /> Repair Work Done U Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter P <br /> Filler Material & Depth ^ <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I aviailablerwthin 200 f et-1, it public sewer is <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms .� Water table depth r <br /> Character of soil to a depth of 3 feet: f No. Compartments <br /> Capacity <br /> SEPTIC TANK ❑ TypelMeg .f Method of Disposal <br /> PKG. TREATMENT PLT. ❑ *Y =� Property Line - Q <br /> Distance to nearest: Well r Foundation <br /> f y.� <br /> 'L�. No. & Len Length-of !_fines Total length/size <br /> LEACHING LINE _ g Pro err Line <br /> FILTER BED n- Distance to nearest. Well Foundation P Y t <br /> SEEPAGE PITS l 1 Depth <br /> --=� Size -- - - ---Number <br /> SUMPS (LI .Distance to'nearest:\ `.Well' <br /> f' : Foundation 1" Property Line <br /> I DISPOSAL PONDS ❑ <br /> � prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have <br /> 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 she 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: 111 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 /> f The applicant t call for all required i <br /> Signed Xns ctions. omplete drawing an r rse si <br /> j S <br /> Title: <br /> F R DEPART ENT USE ONLY ` <br /> V Date I4:;� rea <br /> Application Accepted by 'J <br /> Pit or Grout Inspection by <br /> 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 /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> I{ INFO <br /> ! . EH 53-Y41PEV.iixei <br /> Q ��� <br /> EN 14.76 <br />