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i4 <br /> II SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �nn <br /> P O BOX 2009, STOCKTON, CA 95201 f <br /> SA Li/"by j A rtnny <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> If _(Complete in Triplicate) <br /> II <br /> Application is hereby made to San Joaq is 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.`51+9 and 1962 and the Rules and Regulations of San <br /> Jrruin County Pub l c Hea t Services. � ] <br /> �! 1 � A Ile <br /> Ci y Lot Size/Acreage <br /> Jdb Address <br /> ZZ�o )ccs: SIO 3�?a-33? <br /> owner's Name "w"� S Address t Phon <br /> E� <br /> Contractor .n Address ZME• - License No. !;� Phone - 3 <br /> I <br /> TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ ❑Me <br /> q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER) aa ❑ <br /> !€ `ai�# <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fLD. <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL bCr>!, S <br /> I <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA GONSTRUGTION SPECIFICATIONS <br /> [4 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g A�) <br /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �— r <br /> F1 Public CI Other ❑ Delta Depth of Grout Seal Type -4 <br /> 1'.1 Irrigation __ ApproK. Depth I I Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done U Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> .!I Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> P <br /> Installation will serve: Residence_ Commercial_ Other <br /> �t Number of living units: Number of bedrooms <br /> II Character of soil to a depth of 3 feet: Water table depth <br /> , <br /> k <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> E Distance to nearest: Well Foundation Property Line <br /> + Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines 9 <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> ii <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> certifies the following: "I certify 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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> SignedTitle: + g <br /> 66p>-4 tST Date: <br /> FOR E TMENT USE ONLY <br /> VJ <br /> Application Accepted by Date Area <br /> 5-1a <br /> a87'� Date <br /> Inspection Pit or Grout Inapectn by Date Final Inspection by <br /> it <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY TE PERMIT"NO. <br /> IE� �IN}FO (,/y <br /> . Emt 13-21 1REV.i i e 5} \ I <br /> EK 11.2E <br /> ✓, CJ 1 <br />