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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2049, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete;ait 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services." �5 'j� f� ,� <br /> Job Address 9,1 �00 FP_e tic ` CyitY � Lot Size/Acreage F���"`�� ._ <br /> Owner's Name ! Q Addressovt r Phone clef <br /> Contractor �✓ ?�`- ' �-Address U `' 'v icense No. �y37J 8 Phone E?2S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION D Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION-i '- AGRICULTURE WIf&, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL'S PR06LEM AREA CONSTR&TION SPECIFICATIONS <br /> n industrial ❑ Open Bottom D Manteca Dia- of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications <br /> I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout t <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Sesi Installed by <br /> Repair Work Done v Type of Pump r H.P. State Work Dona _ t <br /> Well Destruction ❑ Well Diameter sealing Material h Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAIRIADDITION W DESTRUCTION ! I (No septic system permitted if public sewer is <br /> �,/ , •+ available within 200 feed 1 <br /> Installation will serve: Residence y Commercial Other <br /> Number of living units: AL—_ -Number, bedrooms-= —--- ti <br /> Character of soil.to a dspth�of 3 feet: r� Water table depth <br /> SEPTIC TANK -❑ Type/Mfg r C C Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I I Method of Disposal <br /> f Distance to nearest: Well i Foundation Property Line I <br /> LEACHING LINE Cl,,,�Io.r.& Length of lines Q 0` I Total length/sire <br /> FILTER BED- 0 t Distance to nearest:i Well Foundation Property Eine [( <br /> SEEPAGE PITS,f III 'Depth Size f Number <br /> SUMPS LI ' Distance to nearest: WeIL Foundation Property Line <br /> -- .; .. i <br /> DISPOSAL PONDS1-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 -,p# <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 ps ormance 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 or all r dinsctions. Co mplete drawing on reverse side. <br /> . <br /> Signed X '" Title: '�`' x"' Dater <br /> FOR DEPARTMENT USE ONLY Q ) <br /> Application Accepted by <br /> Date s Area d--a QLA.11, <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> >t` 6 � •o r ► <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Healt Services <br /> Environmental Health Permit/Services <br /> 445.N•San-Joaquin,P-O-Box 2009; 8tkn,-CA�95201 T <br /> FEE AMOU T DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EN 13.14 It1EY.I/MSI `1t: / <br /> EH 1428 •••11� <br /> ` i' <br />