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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 /> PF"IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete:Fin 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/Hes-.1�tth Services, <br /> Job Address <br /> f-.� C300 IZC' j �CS Ply 6 �r Lot Size/Acreage <br /> C-•-- <br /> Owner's Name _TJ M. S <br /> ,�� Address A41� _ � Phone ,5 <br /> l:✓"� .�C E o L% .� 9 TU.0 t'S,{f �� rf Phone!�2 S <br /> Contractor �f'J� Address � E�icense No. � <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well C f <br /> PUMP INSTALLATION C SYSTEM REPAIR ! OTHER i Monitoring Well C7 {f <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 CONSTRUCTION SPECIFICATIONS <br /> C: Industrial t7 Open Bottom ❑ Manteca Dia. of Wail Excavation Dia. of Well Casing <br /> Ci Domesticl Private CI Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> I'1 Public 1.1 Other n Delta Depth of Grout Seal Type of Grout r <br /> I i Irrigation __ Approx. Depth I [ Eastern Surface Soul Instalied by <br /> Repair Work Done :J Type of Pump ' H.P. State Work Done _ <br /> Well Destruction C Well Diameter Sealing Material & Depth f <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' 1 REPAIRJAODITION V DESTRUCTION< ; INo septi system permitted if public sewer is <br /> + available within 700 feet.} j <br /> Installation will serve: Residence_k"Commerciai�- Other <br /> Number of tiring units: <br /> Character of soil.,,a depttt,.of 3 feet: `� I Water table depth <br /> SEPTIC TANK - Type,'Mfg � 4 Capacity No. Compartments 11 f <br /> PKG. TREATMENT PLT. C # Method of Disposal <br /> Y <br /> Distance to nearest: Well I Foundation Property Line <br /> LEACHING LINE ❑+,No]-.& Length of lines �1�1 <br /> o� `oral length/size � I <br /> , <br /> FILTER BED- 0 6 Distance to nearest:� Well � Foundation _.1.._v Property i.ine <br /> SEEPAGE PITS`f,- I I: Depth Size Number ti <br /> 1 <br /> SUMPS ` Ll r Cistance to nearest: WeIL Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepay d this application and that The work will ba 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 shalt nor <br /> employ any person in such manner as to become subject to workman's compensation laves of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in Itis pe ormanoe of the work for which this parmit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant or � <br /> all r m <br /> d in lions. Complete drawing on reverse side. / <br /> Signed X � �rT Title; ! Date: � <br /> FOR DEPARTMENT USE ONLY t}�� <br /> Application Accepted by Q+ao u'- .y�� — Data Area <br /> Pit or Grout Inspection by Date Final Inspection+, by Date 1p ._ <br /> t <br /> e w� < <br /> Additional Comments; 5\Y, Cr4%_ . <br /> Applicant - Return all copies J. San Joaquin County Public Hea:,t Services <br /> Environmental Health Permit/Services <br /> 445•N•San••Joaqui-n,-P-0.-Box•2009-i -3 tkn,-CA--95201 f <br /> FEE AMOU T cm AMOUNT REMITTED CK RECEIVED BY DATE f ERWT NO. <br /> INFO <br /> . EM 11744AEV,tI>ti5t J 1 { <br /> 6H 7440 � �.£.V�.•V r� <br /> a <br />