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t2pVLA I CAT x ji' <br /> SAN .QUIN COUNTY PUBLIC HEALTH IVICES <br /> `ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> /Services. <br /> /��T <br /> Job Address I / 0 0 a / a n /1{ / __ City�1���� <br /> Lot Size/Acreage <br /> t ' <br /> Owner's Name ADQ214ddres3 s ` _ Phone <br /> Conti ecter Address .�+�" License Ntj/ Phone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T 11 DESTRUCTION D Out of Service Well Cl <br /> PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER O Monitoring Well <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 /> (1 Industrial ❑ Open Bottom 11 Manteca Dia of Well Excavation _ Dia. of Well Casing <br /> (I Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing__ Specifications _ <br /> I'I Public I 1 Other I 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L> Type of Pump H.P. _ State Work Done _ Q <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Z;e/ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence / Commercial Other <br /> Number of living units: Number of bedrooms _� x <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. 0 p *��� Method of D}'�Posal <br /> Distance to nearest: Well foundation s� Property Line -�e`=- <br /> LEACHING LINE No. 6 Length o1 lines �otal length/size <br /> FILTER BED C1 Distance to nearest: Well ,� Foundation Property Line _ <br /> u' <br /> SEEPAGE PITS X Depth TiwAiZize Number _ <br /> SUMPS L_I Distance to nearest: Well ion . Property Line <br /> DISPOSAL PONDS O 1 <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'r 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 minnor asrto btcome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the loh6winol "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion laws of California." <br /> The applicant E 11 for all raq r d i spections. Co pl a drawing on reverse side. n, <br /> Signed X_ o , ( Title: I Date: ✓ i <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by _ Date �y Area <br /> Pit or Grout Inspection by Date 4 Final In Pection by XltDatd <br /> Additional Comments: <br /> e Applicant - Return all copies I San Joaquin County Public Health Services A <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13 N InEV.l i e —v 9 T5 (:?3- 0EH 1,.7! L <br /> v <br />