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r <br /> SAN JOAQUIN COUNTY PUBfJ1C HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, f)HONE (209)468-3420 <br /> P 0 BOX 2009, STOCK-TON, CA 95201 <br /> R <br /> PERMITEXPIRES 1 YEAR FROM DATE ISSUED0 (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the_vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the-Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address (3a(a Q_c. -; .���-- Citys—TX. Lot Size/Acreage <br />�y Owner's Name�� 1,)' Address *'01 Phone <br /> Contract r Addresgig License N��rd�,Phone <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR,i" OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS € <br /> n industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation , Dia. of Well Casing <br /> Xbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_' i Specifications G(,I'1 Public [1 Other F1 Delta Depth of,Grout Seal Type of Grout I i Irri ation Ap rox. De th I Eastern Surface Seal Installed by <br /> Irrigation R P <br /> H.P. state work Done <br /> Ke <br /> Repair Work Dane Type of Pump � � � — <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth � .1 <br /> .r r <br /> Depth; Filler Material & Depth' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDITION I 1 DESTRUCTION I I lNo septic system permitted if public sewer is <br /> If available within 200 feet.) <br /> installation will serve: Residence Commercial— Other � <br /> 1 <br /> Number of living units: ,Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity. No.. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> x' <br /> Distance to nearest: Well Foundation .Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size � <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS 11 Depth Size Number <br /> r ; <br /> SUMPS 0 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 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." Contfactof's hiring or sub-contracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ'persons•subject to workman's c pensa- <br /> tion laws of Calif rnis." <br /> r <br /> The appli mu call for all required ins ctions. Complete drawing on river 1. <br /> r <br /> Signed X Title: { Date: <br /> i <br /> [� ®FOR DkPAOTMENT USE ONLY <br /> Application Accepted by �t •�• 1�-�Q Date <br /> Pit or Grout Inspection by Date Final Inspection by Date D 6 Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health rmit/Services <br /> 445 N San Joaquin 0 Box 009, Stkn, CA 95201 <br /> IF <br /> 0 AMOUNT DUE AMO T REM TIED CKSH RE IVED BY ATE PERMIT N0. <br /> EH1 -11IREV.riNsi � ` 9 / <br /> #H t4•26 <br />