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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> D'fiNIT EMIR95 1 YEAR rNM DATEIIffl <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in eoupliance with San Joaquin County Ordinance No. .549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. h <br /> 4865 E. 8 Mile Rd. City Stockton Lot sise/Acreage 6 acres <br /> Job Address <br /> 931 <br /> Owner's Name Robert Lindstrom Address 4 8Mi1 R -CTnrkt.nn Phone <br /> Contractor Hennings Bros. address 3525 Peldndale mod. License No. ___Z2Q513 Phone - <br /> 1195 <br /> TYPE OF WELL/PUMP: NEW WELL ,')( WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ 50t .- SEWER LINES DISPOSAL FLD. IQQI PROP. LINE <br /> �'' FOl1NDATION� ' �- -AGRICULTURE-WELL-- OTHER WELL-_-fX0 PITS/.SUMPSr�... <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing 1�� <br /> XXDomestic/Private XX Gravel Pack ❑ Tracy Type of Casing PVC Specifications.. <br /> R Public . !-1 Other ❑ Delta Depth of Grout Seal �0 Type of Grout <br /> 0 Irrigation �,. Approx. Depth ❑ Eastern Surface Seul installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth i <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION 0 lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> T , <br /> installation will server. Residence—. Commercial— Other � i <br /> Number of living units: Number of bedrooms _ <br /> A Water table depth " <br /> Character of soil to adepth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfp Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line` <br /> LEACHING LINE ❑ No. S Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> x r, <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line - � <br />,.. ..,:-DISPOSAL PONDS---r0 <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: "f 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 drawin reverse de. <br /> Signed <br /> Hennings Bros. By Tit Date: 2-27-91 <br /> r <br /> Application Accepted byr4u'4,� <br /> FORE TMENT USE ONLY -Date `� Aroa <br /> Pit or Grout Inspection by Date �d Final Inspection by Date fd Q <br /> Additional Comments: wtgS <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> EEE AMOUNT DUE AMOVNT REMtTTED CK H RECEIVED 9Y DATE PERMIT NO, <br /> INFO <br /> . EH 13•24 Mev,I/K5; <br /> EH 7/ffi <br />