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SAN JOAQUIN COUNZ`Y PUBLIC 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 /> S <br /> Application is hereby made to San J. Lt uSancJoaquinocounr a ty ordinance ermit to nNo. 549struct gand a1862 and the r install eRules andwork eRegulations in dof Sans <br /> application is made in compliance wl <br /> Joaquin County Public Health Services. �N ` A M�r-(A �o %NC <br /> aL r(A City i'1 Lot Size/Acreage It <br /> Job Address m I ,p <br /> STe ►� �e-t� Phone <br /> Ve <br /> Address <br /> Owner's Name � 7L. �i <br /> s'�/ �� 391 8 Phon 3 (v 591' <br /> Contractor�— <br /> oll� Address ��� cense No. <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service dell I ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 <br /> OTHER ❑ Monitoring Well cl <br /> SEWER LINES �-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK I— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA.?,-CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications- <br /> '� Type of Casing_ <br /> [-1 Domestic/Private ❑ Gravel Pack7i 0 Tracy /�, .;depth of Grout Seal Type of Grout <br /> i'1 Public is Other <br /> I I ifrioation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Sealing Material & Depth (Tti <br /> Well Destruction ❑ Well Diameter I Filler Material S Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I 1 anvailableseptic <br /> wthin 200 feet.) <br /> TYPE permitted <br /> public sewer is <br /> Installation will serve: Residence +! Commercial ther <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 teat: ' - <br /> f <br /> L& %6, Capacity Ud w =Water table.depth <br /> No. Compartments <br /> j SEPTIC TANK C)'TyPe/Mfg ;r*""' Method of Disp?sal <br /> I` r Q <br /> PKC. TREATMENT PLT. C]'� �p Pro ert Line —:- <br /> Distance to nearest: Well Foundation' p y <br /> I g t Total length/size <br /> ty <br /> LEACHING LINE 'L�No. & Length.of Itnes'� - � ti <br /> FILTER BEDS Foundation �d Property Line <br /> E.] Distance toy nearest: Well�_ � ;. <br /> lI I Depth Size Number r <br /> SEEPAGE PITS property Line <br /> I SUMPS'{,.! r `��`'Ll Distance-to-nearest: ..rWell�-� Foundations <br /> DISPOSAL'PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done ih 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 the work for which this permit is issued, I shall not <br /> 11 employ any person in such manner as to become subject to workman's compensation laws of California."rnContractor's hiring csub-contracting signature <br /> certilies the following: "I certify that in the pert ants of the work for which this permit is issued, I shall amp <br /> lay persona subject to workman's compa�nsa <br /> tion laws of California." it <br /> The applicant for all re d inspe tions. Complete drawing on reverse side. Z ,, �� , <br /> /_ <br /> Signed <br /> r44�, Title:' ( Date: <br /> u <br /> OR DEPAR�1"erlT USE ONLY r <br /> Area (,,,J- Date Application Accepted by <br /> Date—Fins I Inspection <br /> Pit or Grout Inspection by <br /> t� <br /> Additional Comments: <br /> Applicant -�Eeturn 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-9520i r <br /> 17 <br /> FEE AMOUNT DtJE AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. <br /> INFO CASH I f <br /> Af- <br /> EH 14.2E <br /> 4, �/ { <br />