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y <br /> 4 r SAN JOA UIN COUNTY PUBLIC HEALTH SERVICESES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> l ' 445 N SAN,JOAQUIN�,;�P.HONE (209)468-3420 <br /> 1 P O BOX­260b, STOCgTON, CA 95201 <br /> 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Sery cee. <br /> GLr Lot Size/Acres e <br /> Job Address � K City 13 <br /> �49��"� Q Address �_1C� ,!_L.____ j411- 4?46 <br /> Owner's Nama __�____ �- �rw-r��.. G 7 Phone <br /> Contractor �- �..% ddress ti O� �x � _±X7ense No.[A13 73 Phone y <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION -%AGRIC.ULTgRE WELL`* k OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRR&W EM AREA CONSTRUCTION SPECIFICATION_S <br /> n Industrial ��Qpen Bottom ❑ Manteca Dia. of Well Excavation DPa—of-Well Casing r <br /> El Domestic/Private ❑ Gravel Pack, 0 Tracy Type of Casing_ Specificitons <br /> FI Public 1.1 Other n Delta Depth of Grout Seal Type of Graui� <br /> I I Irrigation / Approx. 'Depth I I Eastern Surlsce Seai installed by <br /> Repair Work Done & Type of PumpIr5 k�a H.P. IX State Work Done <br /> Well Destruction ❑ Well Diameter ' Sealing Aterial & Depth 91116r A, <br /> ...�• <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I I INo septiosystem permitted it public snwei`is <br /> aIailable_within 200 feet.) <br /> Installation will serve: Residence _ _ 1 Nmerclal OtherNumber of living units: Number ooms r ) <br /> _ Character of soil to a depth of 3 feet: F f`r I �'' V,_t,r table depth <br /> SEPTIC TANK 0 Type/Mfg Capacit No. Compartments <br /> PKG. TREATMENT PLT. 0 �1 � Method of Disposal <br /> Distance to nearest: t We Foun ion � Property Lino s <br /> l <br />` LEACHING LINE ❑ Na. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line S <br /> r <br /> t <br /> SEEPAGE PITS 11 Depth SKell-- OU <br /> Number <br /> SUMPS I_I Distance toy nearest: ndation Property Line 3 <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this appticati and that the work will be one in accordance with San Joaquin county ordinances, state laws, and j <br /> rules and regulations of the San Joaquin Coun <br /> Home owner or lic nt's signature certifies the following: "I certify that in a performance of the work for which this permit is issued, I shall h o, v <br /> employ any Pe n in such nner as to <br /> become subject to workman's compensatio laws o1 California." Contractor's hiring or sub contracting signature <br /> certifies the slowing: "I ce if that in the pe rmance work for which this per 't is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Califom K 3 <br /> The ap icant m for 11 req ' d * plate rawing on rev si <br /> Signed Title: 6 Date: <br /> R DEPARTMENT USE ONLY r, <br /> Application Accepted by Oft, -Date <br /> Pit or Grout Inspection by Date Final Inspection by "'-' Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEI D BY DATE PERMIT NO. <br /> FO CASH ,��L♦1 /�J�/,/ <br /> "1,(/IEY.IiAli) <br /> IA <br /> —A"� <br /> i <br />