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s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <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 made in compliance with San Joaquin County Ordinance No. 59 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> jLot Size/Acreage 8 0 <br /> I <br /> Job Address .., 5298 _ Fine Rd._,�, Lin�7Pn Ca _ city_.__ <br /> r <br /> owner's Name Address 495 N- Edi Son Stor_-ktQX1 _ Phone <br /> License No.37� Phone W7-3554 <br /> Contract Address <br /> TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ <br /> OTHER (� Monitoring Well U <br /> PUMP INSTALLATION (k SYSTEM REPAIR ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL! "PROSL:FM—AREA"-"CONSTRUC-TI{)N-SPECIFICATIONS 1� <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ti- Dia. of Well Casing — (} <br /> E Type of Casing- Specifications—- -2 5� ] <br /> It F1 Domestic/Private Gravel Pack ❑ Tracy 9- <br /> I'1 Public 11-1 Other 3 1­1Delta Depth of Grout Seal �7�— Type of Grout n <br /> Irrigalion � SKApprox, Depth I i Eastern Surface Seal Installed by <br /> j Repair Work Done T, Type of Pump _tat rh_ H.P. 7 r; _ State Work Done <br /> Sealing Material & Depth <br /> Well Destruction D Well Diameter , d+ <br /> Depth t Filler Material & Depth a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlADDiTION I I DESTRUCTION•1 I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number ofjbedrooms ;• <br /> F Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK. ❑ TypelMfg <br /> Capacity No, Compartments <br /> PKG. TREATMENT PLT.❑ •. Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> [ FILTER BED ❑ Distance to nearest: Well Foundation Property Lin® <br /> f SEEPAGE PITS 11 Depth —size� Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property;Eros Z <br /> DISPOSAL PONDS ❑ <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 whicki 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 of California." i <br /> Thea icant m t call for II'r ed inspections. Complete drawing on reverse side. <br /> �gzSigned <br /> ` Title: `" Date: 12.428192 <br /> t f FOR DEPARTMENT USE ONLY 1�t q� <br /> 1 Date `d`4q_ Q Area . <br /> Application Accepted by <br /> Pit or� rou 11 <br /> spectian by__ <br /> Date ? Final Inspection by Date r <br /> I _ r <br /> Additional Comments: <br /> I _ .. - <br /> Applicant - Return all cdpies to: San Joaquin County Public Health Services- T , <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMFT'NO. WillINF,0 <br /> 00 ryA^ p <br /> . £H 13-24 1REV. /n Sl 1�"�i 13 "y�� l �� <br /> EH 14.26 , "---�� 11 <br /> f <br />