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a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> P <br /> IV SAN <br /> HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 i <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> P67-310-1 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, i <br /> 1055 �t Size/Acreage �G"t""0 <br /> Job Address � cJ ���"��""" �i' j� <br /> I Owner's Na,9 d ess <br /> 4 Q C1 Phone <br /> i c e n s e No.ZPhone 9 . <br /> a for <br /> TYPE OF WELL/PUMP: ..., NEW WEL WELL REPLACEME ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR L1,0 <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L� � ' DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL BOTHER WELL PITS/SUMPS <br /> INTENDED USE l TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial r- n Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casin jf <br /> n Domestic/Private. <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public K <br /> i.. {talion .Approx. Depth 1 1 ste n / Su ace Seai installed ` <br /> /ilepair Work Done U Type of Pump H.P, �/ State Work Done 0r <br /> (r <br /> Well Destruction ❑ Well Diameter I t Sealing Material & Depth. �Jl Tl <br /> DepthFiller Material & Depth ; v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 II RE PAIRIADDITION { I DESTRUCTION I I INo septic system permitted.if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial '+ Other <br /> umber of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: --- --- - -f Water table depth <br /> SEP71C TANK D Type/Mfg --� `� Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. <br /> El <br /> of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> r <br /> - - 3 <br /> LEACHING LINE D ,No.A Length of lines Total lengthtsize <br /> I FILTER BED CI eDistance to nearest: Well ' Foundation Property Line a <br /> k I <br /> r <br /> SEEPAGE PITS I I Depth Size Number <br /> __SUMPS . L1 Distance to nearest: Well Foundation Property Line I: <br /> DISPOSAL PONDS. ❑_ ' <br /> I hereby certify that_I have prepared this application and thattihe work will be done in accordance with San Joaquin county ordinances, state laws, and ' <br /> rules and regulations of the San Joaquin County <br /> Homeowner 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." Contractor's hiring of subcontracting signature <br /> certifies the following: "1 c rtify that' a perto mance of the.work for which this permit:Zd shall employ perso a subjec —to o wofkman's compensa <br /> tion laws of Caiitornia." kw- �____ ; <br /> The appli L ust c r I e i g on reverse si e. " <br /> Sig a rias: Date: r <br /> FOR DEPARTMENT USE ONLY q I <br /> Application Accepted by Date ` `Z— Area Q <br /> Pito Grout apection by ate Af <br /> f 9Z Final Inspection by Data V �� <br /> Additional Commentr. 86 w �rty <br /> Applicant - Return all copies to: San Joaquin County Public Health Services fU�e �DS ? <br /> Environmental Health Permit/Services -ru <br /> 445 R San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOtfflT REMITTEDCASH RECEIVED SY DATE PERMIT NO. <br /> j <br /> EN 1 3-24 IREV.1/nSY Y1. ' lV>fA4 <br /> EH 14.286 V <br />