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E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> `. 445 N SAN JOAQUIN, PHONE (209)46$--3420 i <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> f. i� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II <br /> (Complete in Triplicate) r EY70 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. i1This <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. <br /> QrnQ( <br /> Job Address Cit y Lot Size/Acreage <br /> �' p p <br /> Owner's Name a;—P— +r`� � f-VQ - — Address �f r 0 Phone 511 <br /> Contrattar <br /> I�1 6L1Yt Address d License No. 3WSSS Phone C <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well CI " <br /> PUMP INSTALLATION 1A SYSTEM REPAIR ❑ OTHER E) Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _b� it Ga <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca ,. Dia. of Well Excavation Dia. of Well Casing <br /> (X Domestic/Private Or Gravel Pack Ll Tracy Type of Casing_ Specilications <br /> ('I Public i-1 Other f -- —. n Deita.- — - „,..Depth of Grout Seal T E� Y - Type of Grout <br /> i I Irrigation -�ZA74/Appmx. Depth I I Eastern'. Surface Seal Installed by ij <br /> Repair Work Done L7 Type of Pump 4uhm . H.P. State Work Done I; <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth !I <br /> Depth Filler Material iL Depth [j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sawel` is <br /> available within 200 feet.) II <br /> Installation will serve: Residence_ Commercial s -Other. <br /> q <br /> Number of living units: Number of bedrooms { <br /> Character of soil to a depth of 3 feet: r y k ' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl <br /> J < Method of Disposal !� <br /> Distance to nearest: Well Foundation Property Line II <br /> F 1 <br /> length/size <br /> it <br /> LEACHING LINE ❑ Na. & Length of lines Total len g <br /> FILTER BED ❑ Distance to nearest: Weil- Foundation Property Line <br /> .SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> -1 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 it <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, Iishall not <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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californ l i <br /> The applican st call for all required inspections. Compl e rawing on reverse side. II <br /> ti_-.c_ Date: "— <br /> Signed Title: �� <br /> FOR DEPARTMENT'USE ONLY <br /> A plication Accepted by Date _.._ Area <br /> L <br /> p _ <br /> Pit<Grout spection by ate inel Inspection by Date <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services i <br /> Environmental Health Permit/Services <br /> .445 N San Joaquin, P O Box 2009, Stkn, CA 95201 !' <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EM I]•2�IREV.r�n Sl w p ©Q 1 r � <br /> y eH 14.2E / III <br /> t <br />