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SAN JOAQUIN .COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL BEALTH DIVISION <br /> 445 N .SAN-40AQUIN, PHONE (209)9668-3420 <br /> P O "BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATI- ISSUEDD_ <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a persist to construct and/or install the work herein,. Iescribed. This <br /> application is made in coapliance with 13au Joaquin County Ordinance No. 51+.9 and :L1362 and the.Rules and Regulations of San <br /> ^ <br /> Joaquia County Public Health Services. <br /> Job Address City� L;tS� Lot Size/Acreage <br /> ..". <br /> ( Phone <br /> Owner's Name —�-- Address <br /> Contractoi ���GGA— Address F-1-Z;->,, /�b �icense N � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well D <br /> C DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISP05AL FID. PROP, LINE <br /> F FOUNDATION AGRICULTURE WELL OTHER.WELL PI.TSISUMPS <br /> INTENDED US£ TYPE OF WELL PROBLEM AREA ',CONSTRUCTION SPECIFICATIONS <br /> — <br /> n Industrial ❑ Open Bottom © Manteca Uia. of Well Excavation __ Dia. of Well Casing <br /> f] Domestic I Private Cl Gravel Pack ❑Tracy Type of Casing_ Specifications <br /> i'I Public Cl Other 1-1Delta Depth of Grout Seal Type of Grout <br /> ' Surface.Saul Installed by <br /> t I IrriUation ...._.Approx. Oepth„�.4.LEastern..�,,.,_ ..,. <br /> { Repair Work Done L7 Type of Pump H;P. State Work Done �A! <br /> Well Destruction ❑ Well Diameter sealing Materiel i Depth k I'IJ <br /> Depth Filler Material i Depth <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sawer is 0 <br /> available'within <br /> Installation will serve: Residence Commercial! dther <br /> Number of living units: T Number of bedrooms ' '°"i r <br /> Character of soil to a depth of 3 feet: 1 Water table depth 11 <br /> SEPTIC TANK ❑ Type/Mfg Capacity '_N6. Compartmenkii <br /> PKG.TREATMENT PLT.❑ ��j Method of Disposal- r,}( <br /> Distance to nearest: Well Foundation _ Property Line l'7 <br /> LEACHING LINE X No.& Longth of lines Total length/size' <br /> k FILTER BED Cf Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS 11 DepthJ� ie v - '"""""Number Z <br /> SUMPS Oistance to nearest: We111o22t1xT Foundation ` Property Line <br /> DISPOSAL PONDS C] <br /> I hereby certify that I have prepared this appl'icatlon and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and. <br /> rules and regulations of the Sen Joaquin County '• <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performanco 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 compensation laws of Caiilornia."Contractors hiring or sub•contrecting signature <br /> cenifies the following:"I cenity 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 applicant mull tall for allad in omplete drawing on reverse side. , <br /> Signed _ ��`Title _s� � Date: <br /> ?t <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Y7, 1 Dow '�RZ Area <br /> Pit or Grout Inspection by 1' 'r Date Final Inspection b} Oats 2- <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: -•tiaa Joaquin County,Public Health Services <br /> r —Enbironmental Health Permit/Serviceia <br /> •,.`445.N San.4oa4gin r 0.I3ox• 2009;<-StItn -CA-,95202• p '^ - _ <br /> ]FEEAMOUWT DtfE AMOUNT REMITTEO K RECEIVED fay DATE PERMif' 6' <br /> 150 <br /> EH ti-21 MEV,rin6r �1 ` llJ6 a q 2Z <br /> EH Was <br /> i T <br /> 1 <br /> 4 - <br />