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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N 0 try <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� <br /> ,1 (Complete in Triplicate) 'AVO <br /> Application is hereby trade to Sap 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 Ordiryance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services./ /j j� l ,\ / �/� <br /> �/ Vr'f / \ 1 ��' City ����" ""tl°"t Size/Acreage <br /> Job Address y, g r Com»#� 11 <br /> ]� /f ` S /d / phone _� <br /> Owner's Name 8 t'vi `I R7 Address <br /> 7 L <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h <br /> „1 I <br /> n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private 0 Gravel Pack7 L7 Tracy Type of Casing_ Specifications <br /> I'1 Public i-1 Other n Delta Depth of Grout Seal Type of Grout { <br /> I I l(rigation _..Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth 1 Filler Material"& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION At iNo septic system permitted if public sewer is ; <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> :i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ci Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length!of lines Total length/size <br /> k <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> A <br /> 11 <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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." I <br /> The applicant mor all required inspec ions Complete ra>dvn reverse si .L/ <br /> Signed X Title: pate: <br /> FO DE RTMENT USE ONLY <br /> -C, <br /> '] <br /> Application Accepted by Date -� � - Area <br /> Pit or Grout Inspection by Date Final Inspection by Date T�la <br /> l <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services fE <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> e i <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EH t3 <br /> •M IREV.i r RS 4 o <br /> ci <br /> -� <br /> INFO <br /> 114'M <br />