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L� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> r" 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> x P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pr ,(_A � cF� .,� <br /> l.tC=(_A (Complete in Triplicate) D , � ! <br /> Application is hereby made.to SanJoaquinCounty for a p6rcnit to construct and/or install the work herein described. This <br /> application Is made in compliance,vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Courftfut11p.]iV1 sIry l" E� of Gettyburg <br /> Job Address <br /> Placetrtr& 1°11112110' S. of Douglas Rd. city Stockton Lot Size/Acreage <br /> County of San Joaquin <br /> Owner's Name Dept. of Public WOrkSkddress 1810 E Hazel tnn,Stno1rtnn Phone (6,$ 3000 <br /> Contractor <br /> Diablo Pump C,�. Address License Iva. 639090 Phone 510-687-9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EM NT Cl DESTRUCTION)C1 Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> a <br /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> i'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by 4 <br /> Repair Work Done 0y Type of Pump' H.P. State Work Dona — <br /> Well Destruction L5' Well Diameter 10" Sealing Material & Depth t t P QQ ement +• <br /> Depth 1951 Filler Material & Depth 1101 to 195 ' grout <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence i Commercial— Other <br /> Number of living units: Number of bedrooms <br /> F Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments N� <br /> PKG. TREATMENT PLT. 0 Method of Disposal V)y <br /> Distance to nearest: Well Foundation Property Line "r <br /> LEACHING LINE C1 No. & Length of lines Total length/size ' <br /> 1 FILTER BED n Distance to nearest: Well Foundation Property Line <br /> 3 C <br /> SEEPAGE PITS 11 Depth Size Number" <br /> SUMPS El Distance to.,nearest: Well Foundation - Property Line <br /> f 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'Coimty', I <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 I , <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 a <br /> canifies the following:._'l 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 Californis." ` <br /> The applicant mu t I f r allrequire sPections. Complete drawing on reverse side. _I,) l <br /> i contractor/owner July 15 , 1992 <br /> Signed Title: Date: <br /> FO DE RTMENT USE ONLY `� f� <br /> I Application Accepted by Date / �w� 2 res <br /> a <br /> # Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Coun y Public Health Services <br /> Environmental Health Permit/Services <br /> i 445 N San Joaquin, P O Box 2009, Stkn, CA'95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> t INFO <br /> y. VI <br /> (1rb"IZEM13.241RE / 2A7- <br /> EH 14.2E �� ~ <br />