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f S Ji/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> f P O .BOX 2009, STOC%TON, CA 95201 <br /> K r <br /> PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED <br /> (Complete in Triplicate) <br /> r' Application is hereby made to Sam Joaquin Count for <br /> Y a permit to construct and/or inetal.l the work herein described. This <br /> application is made in Co®pliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi es. <br /> f = <br /> Job Address City _L Lot Size/Acreage <br /> Owner's Name _ Address Phone <br /> Contractor Address License No.QLE,W_Phone <br /> 03 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTt.1DESTRUCTION ❑ Out of Service Well ❑ . I <br /> xpk PUMP INSTALLATION ❑ SYSTEM REPAlfl OTHER p Monitoring well ❑ .'' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> FOUNDATION• _ -AGRICULTURE WELL., .OTHER WELL. I PITS/SUMPS_�__..� ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS; <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l <br /> /� Dia. of Well Casing <br /> fa <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ l <br /> t 9 TypefGrSpecifications <br /> t i'1 Public Ci Other "4 (� Delta � Depth of Grout Seal � Type of Grout <br /> .01XIrrigation Approx. Depth I I Eastern �._ Surface Seal Installed by _= � <br /> Repair Work Done ❑ Type of Pump <br /> State Work Doris V ` <br /> Well Destruction ❑ Well DiameterSealing Material & Depth <br /> ',. Depth Filler Material 3 Depth <br /> TYPE OF'SEPTJC-WORK: NEW INSTALLATION I I REPA17ADDITIUN i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r 1 r available within 200 feet.) <br /> Installation wllh.seive: Re'sidence'— Commercial— ;Other <br /> I Number of living un ts: —'-Number of bedrooms ^ <br /> Character of soil to a depth of,3 feet: <br />€ SEPTIC TANK l Water table depth E! <br /> ❑ Type/Mfg f Capacity No. <br /> PKG. TREATMENT PLT. C7 <br /> Distance to nearest: Wel! Foundation / repro art <br /> PECOWEIV , <br /> ar l f <br /> LEACHING LINE ❑' No. & Length of lines Tota! length/size <br /> FILTER BED C] Distance to nearest: Well j - Foundation prop hJ1 AQU1l <br /> SEEPAGE PITS 1 1 Depth Size _ ' f'r �1 <br /> _ i uivy nvivi lu.� EA4!` . <br /> u r <br /> SUMPS L7 Distance to nearest: Well Foundation J mb � . <br /> � r <br /> Property Line. <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 f <br /> Home owner or licensed agent's signature certifies the following; "I certify that iri.the performance of the work for which this permit is issued, I shall not <br /> employ any parse such manner as to become subject to workman's compensafion`Iaws of California."Contractor's hiring or sub-contracting signature <br /> certifies the foBo Ing "!certify that in the performance of the work for which this perm`tissued, I shall employ persons subject to workman's compensa- r <br /> tion laws o or a." <br /> The app a t call for all requi s inspectign omp a`drawing4rlelvea side.Signed - <br /> ~ 0 Date: — <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> - •':Date �� .� �.. Area �— <br /> �_ Pit or Grout inspection by <br /> date _F_inal Jnspection_by_ <br /> Additional Comments: <br /> Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services <br /> 445 N San Joaquin,-P O Box 2009, Stkn, CA 95201 <br /> a FEE AMOUNT DUE CKINFO AM NT REMITTED <br /> ECEIVED BY DATE PERMIT N0, L <br /> • E 12 1REV.4/NS) i <br /> EHR 11.4.2a � ���D s / <br />