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,1� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i� (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct andd 1 install the work herein described. 6 <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicfa. . <br /> )AD LL O Y O c^T <br /> 1(�rti � City� �- Lot Size/Acreage t <br /> .lob Address � <br /> `jr ,Mme.. OtS212 Phone_ 26Z <br /> Owner's Name 13 Ue �� Address } <br /> ' <br /> Contractor <br /> 1 Address z Z 5` License No.5p',W _3 Phone <br /> TYPE OF -ELLlPUMP: NEW WELL ❑ ,WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑4 . SYSTEM REPAIR i 1 <br /> DISTANCE 70 NEAREST: SEPTIC TANK ISEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL_ ' ,OTHER WELL r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Industria! ❑ Open Bottorrl ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> IsY6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> Il Public Cl Other -_._ Cl Delta Depth of Grout Seal <br /> I I Irrigation i Approx. Depths I,I2Eastern Mrfce Seul Installed by t t r_/V 0S6�1Repair Work Done L1 Type of Pump, H•P• State Work Done��� <br /> Well Destruction ❑ Well Diameter'f Sealing Material & DepthIn <br /> :. ,'j Filler Material A Depth <br /> Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION { I DESTflUC710N l 1 aNailabetrwithin 200 feetc system .) if public sewer is <br /> k Installation will serve: Residence fkCommercial Other -- <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: - __ _ No. Compartments <br />`I SEPTIC TANK ❑ Type/Mfg I - - - =Capacity--"-`- <br /> t� Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> Distance tri nearest: Well Foundation Property Line <br />!!! LEACHING LINE C1 No. & Length of tines Total length/size <br /> FILTER BED 0 Distance to!nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 1 Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Joaquih County <br /> Home owner or licensed agent's iignature 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 tobecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in th.e 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' <br /> The applicant must call for all required ins_ ns. Complete drawing on r rse side. 7 c,; � - <br /> Signed X <br /> Title: Date: G��l <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by <br /> Date Finer Inspection by Z <br /> r <br /> Additional 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 /> FEE CK RECEIVED BY D TE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CJJA}}� <br /> EH11211REV.rin51 <br /> EH 14,28 1�_ <br />