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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCgTON, <br /> CA 95201 <br /> � i <br /> `:PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> k application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. -'k <br /> pp ,lj+- /� <br /> Q L..G City �/'��-' Lot Size/Acreage <br /> Job Address - <br /> 1� 3 -6 73 tS <br /> , Owner's Name � Address Phone <br /> /� x <br /> Contractor <br /> j� Z Address• 6ii !7` License N3;} WAP-"' Phone33 ��� <br /> TYPE OF WELL/PUMP: NEW WELL-Pe WELL REPLACEMENT/ DESTRUCTIO Out of Service Well ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR 11) OTHER p Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.Pa PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL P175/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 46 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation --L- Dia. of Well Casing <br /> 1e _ Specifications <br /> �,AomesticlPrivate 'Gravel Pack ❑ Tracy Type of Casing-_ <br /> I'1 Public 1-1 Other (-1 Delta Depth of Grout Sealer— Type of Grout <br /> I I Ifrigation 'I_kfC..Approx. Depth I I Eastern Surface Seal Installed by < - <br /> ' / _ 2-- <br /> Repair Work Done U Type of Pump �._-- H.P. State Work Done <br /> Well Destruction Well Diam�1, <br /> sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION ( I DESTRUCTION l I (No septic system permitted if public sewer is <br /> i Y "available within 200 feet.! <br /> Installation will serve: Residence! Commercial_ Other <br /> Number of living units: " Number of bedroom$ (� <br /> Character of soil to a depth of 3 feet: N �` ' Water table depth <br /> °..�; '` �% <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal r <br /> ! r` <br /> Distance to nearest: Well Foundation_ . Property Line <br /> d <br /> 1 LEACHING LINE C1 No. & Length of lines t Total Iength/size <br /> l FILTER BED 0 Distance to nearest: Well �" Foundation Property'Line <br /> l t t <br /> SEEPAGE PITS 11 Depth Siie-` Number <br /> SUMPS" UI Distance to nearest: Welli� FoundationF Property Line <br /> DISPOSAL PONDS ❑ ' <br /> 4 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 It, "' <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 taws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I cartify 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." I f <br /> The applicant must all for 11 requi inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: �f�4� = Date: 33 <br /> i r Fli EPA rMENT USE ONLY <br /> WI <br /> I Application Accepted by Rate __.Area ozlk �' <br /> lv <br /> Pi Gro Inspection by Date Final Inspection by Date lS <br /> ' ice , 0- 06/ <br /> A ditional Comments: <br /> Applicant - Return all copies to:, San Joaquin County Public Health Services ' 0 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95207. <br /> FE AMOt}NT DtJE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> INFQ <br /> 3' <br /> . 4D 377�5- <br /> EH 13-24tREv.-rinse/ 3rF7C — 0 6 <br /> EH 14-M '� - <br />