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SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVICES firs , <br /> ENVIRONMENTALHEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N 0 W <br /> P O BOX 2009, ISTOCKTON, CA 95201 <br /> j PE IT EXPIRES 1 YEAR FROM DATE ISSUED , 1a \ � <br /> (Complete- in Triplicate) <br /> Application is hereby made to San Josquirs County for a pert to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health SexYi L <br /> (cJ C5+rte'f, ~ .� //��''�� <br /> �/Job Address - {-- C'ty— Lot Site/Acreage <br /> Owner s Name Address r 'r g (/ Phones` <br /> Contractor u License No. Phone <br /> Address <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl <br /> j PUMP INSTALLATION ❑ 'hY-hYSTEM REPAIR C1 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> kCl Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> Il Public 1-1 Other r) Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation —Approx. Depth I t Eastern Surface Seat Installed by <br /> Repair Wotk Done L1 Type of Pump H.P. State Work Done_ <br /> Well Destruction O Weil Diameter Sealing Material 6 Depth <br /> 1 <br /> Depth Filler Material ix Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DIESTRUCTIONA INo septic system permitted if public sewer is <br /> available within 200 feet.? <br /> installation wits serve: Residence_,_,. Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. © Type/Mfg „ __ - Capacity No. Compartments <br /> PKG. TREATMENT PLT.LI Method of Disposal <br /> Distance to nearest: Wail foundation Property Line <br /> a i <br /> LEACHING LINE ❑ No. fti Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well __- Foundation Property Line <br /> r SEEPAGE PITS 11 Depth Size Number <br /> fSUMPS CI Distance to nearest; Well �� Foundation Property Line <br /> t DISPOSAL PONDS ❑ <br /> i I hereby certify that I have prepared this application and that the worktill be done in accordance with San Joaquin county ordinances. State laws, and <br /> r rules and regulations of the San Joaquin County <br /> I Home owner or licensed agent's signature certifies the following: "I ce fy 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-�ompensalion 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 California." <br /> The applicaAi mustx4l for et required inspections. Complete drawing on reverse side. <br /> igned X Title: Date: 3 <br /> nR <br /> DEPAiRTMENT USE ONLY <br /> I Application Accepted by iyl5. r Area v <br /> Pit or Grout Inspection by _—-_ Date-- - - Final Inspection by Date d 21 <br /> Additional Comments: 88 <br /> Applicant - Return all copies to: San Joaquin Couflty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMil"NO. <br /> . fH13.24IREV,1JRS1 rf . Q�°] /rr•.ar <br /> EH 1676 / vV ,``. [J <br /> �. y,r <br />