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1 . <br /> \\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FR9M 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 in 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 /> Ci Lot Size/Acreage 1, <br /> Job Address 11)l /Im <br /> Phone 7Z �� <br /> Owner's Name rrt,fZ�U y'�AAddddressss� <br /> Contract <br /> Address 1_(C _7/ -`" "—' License No. Z Z Z(o Phone <br /> f service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I DESTRUCTION O Out Monitoring Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fi PROP. LINE _ . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r�1 <br /> ❑ Industrial O Open Bottom ❑ Manteca Oia. of Well Excavation ' Dia. of Well Casing <br /> T f Casin Specifications— <br /> Domestic/Private <br /> pecificationsDomestic/Private CTG�8V61 Pack O Tracy Type .o___.9—- <br /> 17 Other ',k.� n Delta <br /> Depth of Grout Seal Type of Grout <br /> — <br /> ['I Public _ <br /> I Irrigation Approsbepth I"I Eastern r� Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work Done (] 'Type of Pump _ C <br /> Sealing Materiel it Depth `. <br /> Well Destruction O Well Diameter Filler Material Yr Depth- <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ADDITION Fr DESTRUCTION I I INC) septic system permitted if public sewer is <br /> r <br /> available within 200 11 1 <br /> Installation will"Ne: Residence.k/ Commercial= Other -_ <br /> _ _ <br /> a� �'fJumbei ol'GSng unrt§:�'6Nu—m50Trof';tT-r r ms <br /> eel <br /> Character of$oil to a dap of 3 feet: &ter table depth <br /> SEPTIC TANK, 1 Type9Mig l Capacity �O No. Compartments <br /> PKG. TREATMENT PL Ll. r � �-.�� � <br /> / / Method of Disppsal <br /> Distance to earest: Well 16 Foundation 10 t Property Line <br /> LEACHING�L'INE -' No. & Length of tines '— TO length/size X <br /> i <br /> FILTEII ' O Distance to nearest: Well ,.jQ` Foundation �� Property Line .S f <br /> SEEPAGE PITS Depth i! `' Size ��`��� d�umber <br /> SUMPS LI Distance to nearest: Well zl <br /> Foundation-J�— Property Line <br /> DISPOSAL PONDS O <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 cenifies the following: "I conity 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'ro workman's compensation laws of California." Contractor's hiring or Sub-contracting signature <br /> certifies the following: "I comity that in the performance of-the work for which this permit is issued, I shall employ persons subject to workman's comper <br /> tion laws of Californla." <br /> The applican t call ffoo II r i ed inspections. Complete drawing on reverse std <br /> Signed % \ Title: yVLJ Data: <br /> .� � /OR DEPARTMENT USE ONLY <br /> ! Date <br /> Application Accepted by Area <br /> Date <br /> Grout <br /> Pit Grout Inspection bYj._ - ,Date Final Inspection by <br /> Additional Comments: <br /> --Applicant - Return all copies to: San-.Joaquin County Public Health Services f <br /> Environmental HealthPermit/Services <br /> 445 N'San.Joaquin O Box 2009;...Stkn, .CA 95201"1 <br /> I <br /> FEED AMOUNT OUE AMOUNT REMITTE CK ECEIVEO By D TE PERMIT�N0. <br /> tNF _ <br /> + EM 1324tillil" K <br /> EM 1416 <br />