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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> weal 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 Services. <br /> �' r <br /> Job Address City LOD, Lot Si /Acreage <br /> �(' ! "]` <br /> Owner's Name �^+' '` � r_Z3�_ Address �� Phone ~� <br /> Contractor <br /> TL C lt0��` eF_ �feR Address 7 .5tcn License No. ,]Liof;f Phone ?s <br /> TYPE OF WELL/ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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' CONSTRUCTIbN SPECIFICATIONS -a <br /> nIndustrial E3Idpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> almestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ D4ai Specifications <br /> �A <br /> ('I Public r:1 Uther n Delta Depth of Grout Seal 1d1E] _— Type-of Grout <br /> Itel'iriUation —.App(ox. Depth i I Eastern Surface Seal Installed by 104, <br /> �+ w <br /> Repay Work Done L7.' Type of Pump — H.P. 2V — State Work Done <br /> Well Destruction O Well Diameter Sealing Material Depth 1 <br /> Depth <br /> 1 Filler Material i Depth,•. <br /> TYPE`OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IN6'septic `system permitted if public sewer is <br /> _ p available within 200 feet,) <br /> Installation .. -serve: Residence __ Commercial Other <br /> Number of living units: Number of bedrooms �r <br /> Character of soil to a depth of 3 fee . Water table depth <br /> SEPTIC TANK D Type/MfgCapacity No. Compartments"'! <br /> PKG._TREATMENT PLT.0 tha Disposal <br /> Distance to nearest: Well Foundation o erty Line <br /> t <br /> LEACHING LINE ❑ No:& Length of lines �_ Total length/size <br /> FILTER BED Lf Distance to nearest: ell Foundation Property Line i <br /> SEEPAGE PITS 11 Do#h---- Size N6 i, <br /> r SUMPS LSI_Distance io neatest: Well l Foundation 'P`'. Property Line <br /> DISPOSAL PONDS:—❑ ' <br /> I hereby certify that I have prepared this application an -that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the_San.JoaquinTCouniy h - sr.�F-; •-•-- --� --�-. -i. <br /> I Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the work for which this permit is issued,l shall not <br /> employ any person in such manner as to become subjectgo workman's compensation 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 applicant m at call for II req ed inspections. Complete drawing on reverse side. <br /> Signed �� Title: -- ___ Date: <br /> . R FOR DEPAR MEN SE ONLY I ILIr <br /> Application Accepted by # Date Area © 1 Z f <br /> Pit or C16t inspection by Date 7final Inspection by Data <br /> 9 IV11 ' <br /> Additional Comments: �'^ f l e <br /> "'Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services AN <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> f <br /> FEE AMOUNT DUE.I AMOUNT REMITTED I CK 8 -RE EIVED BY DATE PERMIT'NO. } <br /> INFO] CASH <br /> . EH 13-24(REV.i N si w1v <br /> © camp <br />