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�. 4 <br /> SAN t,,9QUIN COUNTY PUBLIC HEALTH VICES <br /> ENVIRONMENTAL HEALTH D I V T S I O �/ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O SOS 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 coWliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health�Se/rvices. / 1 <br /> f Job Address or�� oe�� &ZO� City �/7 Lot Size/Acreage <br /> Owner's Name f 4,,__ffW ze&o --- Address O Z1 Sew few f - urr T Phon.0-0— 6 <br /> Contra / ` d' Qf" Address /¢ rr r e v' License No. Phonef Z — Z01 <br /> TYPE OF EL /PUMP; NEW WELL ' r I f&LC7AfPtX" EN n DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION 3 SYSTEM REPAIR ❑ OTHfR M nito,- 11 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Iq SEWER LINES 0' DISPOSAL FLD. � PROP. LtNE �fQ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J.industrial ❑ Open Bottom G Manteca Dia. of Well Excavation &7 i Dia. of Well Casing / <br /> [l Domestic/Privatev$I�Pbek^ 0 Tracy Type of Casing_�� SGl, �f-Q .. Specifications <br /> I'1 Public N Other vl 4l, Depth of Grout Seal Type o Grout 86A f4dcl A60 17 4-t <br /> I I Irrigation �Approx. Depth 1 i astern Surface Seal Installed by /" <br /> Repair Work Done U Type of Pump H.P, State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I i lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> PAYMENT <br /> LEACHING LINE ❑ No. 8 Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> OCT-1 7 Q <br /> SEEPAGE PITS I ! Depth Size Number CAM 1r%A^t <br /> SUMPS Lt Distance to nearest: Well Foundation Prc0h*L40+W_&LTW•&9R1j10ES <br /> DISPOSAL PONDS ❑ ENVIRONMENTAL HEALTH DIYISION <br /> I hereby certity.1hat 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 /> Horne owner or licensed agent's 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 tnanner as.to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I canify that in'the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The apptican s ail f all r red in ns. omplete drawing on reverse side. <br /> Signed'Jr Title: � -Gr rf�ate: _OR DEPARTMENT USE ONLY <br /> Dat e <br /> Application Accepted by a <br /> Pit or Grout Inspection by Final Inspection by Date <br /> Additional Comments: <br /> i` Applicant - Return all copies to: San Joaquin County Public Health Services O� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 9520.1, �a ;wo kil exl <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> t9� /" / t <br /> EH 1741(AEV.7 Is 51 oO �J 6 - <br /> EN 14.26 LS/ - <br />