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SAN JOAQUIN COUNTY€.PUBEIC 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 /> Applieat`fon 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 IIbounty Public Health Services. <br /> I � � <br /> City Lot Size/Acreage <br /> Job Address <br /> .11 � Address c.�� Phone <br /> Owner's Name�'ale <br /> � Q uL� <br /> Contractor' +of �� t - Address 0 License N C� Phone Z <br /> ell 0 <br /> TYPE OF..4WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service W <br /> Monitoring Well <br /> iiN• ' 1 PUMP INSTALLATION "53r- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' ❑ Indusdial fi ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (-I Domestic/Private '- Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> C1 Public�ll _ ,.1-] Other r # x Cl Delta, Depth of Grout Seal Type of Grout <br /> = E 'P r _ Approx;Depth I astern Surf Sedl Installed by 0 <br /> >1kIrrioation s 1 <br /> k `" tate Work Done L <br /> Repair Work Done Af.�Type of Pump H.P.HP <br /> llSealing blCterial. & Depth <br /> Well Destruction El' Well Diameter ' <br /> Depth Filler Material & Depth <br /> ' TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I.I_.DESTRUCTION.I I.PINo septic system permitted it public sewer is <br /> r q <br /> available within-200 feet.I �1 <br /> instaltatian will serve: Residence— Commercial_ Other t <br /> _;— imbor�of living-units: Number of bedrooms ---� ti <br /> Chsr cter-of s ll-to a depth of 3 feet: Water table depth <br /> t <br /> SEPTIC�TANK ,_p Type/Mfg t Capacity No. Compartments <br /> Method <br /> PKC. TR' ATMENT PLT, C7. of Disposal . <br /> 8...� -.l... ..w <br /> ADi(stance to nearest: Well Foundation ' Property Line <br /> h LEACHING LINE ❑ No. & Length of lines ' Totai.le_ngth/sized 0 <br /> FILTER BED CI Distance to nearest: Well Foundation`' Pioperty'Line <br /> I� <br /> $ SEEPAGE`PITS 11 Depth Size Number <br /> SUMPS l l Distance to nearest: Well Foundation Property Line <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 Aner or licensed agent's signature certifies the following:_4l comity that in the performance of the work for which this permit is issued, I shall not <br /> j 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 vvhidh this permit is issued, I shall employ persons subject to workman's compensa <br /> tion lawe'of' �— "r <br /> The applicant must call for ll'required ins tions. plete draw g on ev se side. <br /> Signed XI Title: Date: <br /> FOR DEPARTMENT�US.E-ONLY <br /> Applicati`on Accepted by <br /> Date Area 2 <br /> Pit or Glraut Inspection by Date Final Inspection by Date l�7 _3 <br /> I Additio 'al Comments: <br /> II <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> i 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> CKS <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13.24 rREV:r 1"5r � <br /> a*r/ , ' 7 ,,�V <br /> EH 14.26 <br />