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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 trade in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Nblic Health Services <br /> j Job Address ' City Lot Size/Acreage <br /> LA J Address `� L-,-hone <br /> F Owner's Name nK C <br /> Contractor <br /> ddress ° r�3 W4�4urnseeNo. y Phone r <br /> fffr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> f PUMP INSTALLATION ❑ a SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ;SEWER LINES DISPOSAL FLD. PROP. LINE <br /> n <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f� Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation t Dia, of Well Casing <br /> Domestic/Private ❑ Gravel Pack i L1 Tracy Type_of..Casing_ 1- s j Specifications <br /> 1'1 Public ! El Other f-1 Deft a Depth of Grout Seal''✓ M Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by j <br /> Repaif Work Done 0 Type of Pumpi H.P. ` State Work Done <br /> I Well,Destructionj ❑ Well Diameter f+ Sealing Material.; Depth <br /> { <br /> i ,f j 6' tib t s Filler Material 8,Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I�REPAIR/ADDITION ( I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> j. available within 200.feet.1t <br /> installation will serve: Residence— Commercial Other ✓" <br /> c Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: "TWater table depth <br /> i �, rtes • <br /> SEPTIC TANK O Type/Mfg Capacity r No. ,� 8 TrZ p <br /> y e iE Y <br /> PKG. TREATMENT PLT. ❑ nearest:,, Wei i Met. a ' <br /> Distance to ll Foundation Properly L1WOMfl <br /> IrANG I <br /> Q 1292 <br /> . <br /> LEACHING LINE 0 No. & Length of lines Total length/���r - <br /> _,vry r <br /> FILTER BED ❑ Distance to nearest:/' Well Foundation Pro 6} LlDr e� -r'VICES <br /> ENVIRONMENTk HFA <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> -�. DISPOSAL PONDS ❑ I f = _ <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'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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cerlifiea the fano g: "I canify 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 f nla." <br /> The applic t t call for all req 'red inspect" s. Complete drawing on ve side. <br /> Signed X C Title: Date: <br /> F : _ -.. . <br /> •- """""""'"" FOR DEPARTME USE ONLY <br /> Ail J' 3' <br /> Application Accepted by pate Area <br /> Pit or Grout Inspection by Date Final Inspection by w Date Z <br /> l .. <br /> ..T-Additional--Eornments: <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK N CEIVED BY DATE PEAMIT N0. <br /> INFO C/�J <br /> . EH17-24(REV.r/nS) P <br /> EH 14.2tl <br />