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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 I <br /> P O BOX 20092 STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 6250 N. Escalon Belotta Rd. City Linden Lot Size/Acreage 400 <br /> Owner's Name Norman' s Nursery Address 8665 E Duarte Rd. ,�a�l- GabrBh®aez—_a_ 91775 <br /> Contractor Purviance Drillers japi.essP. O. Box 64 Linden License No, 377923 Phone — <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION)JR Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS'ISUMPS <br /> iNTENDED•USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. df Well Casing <br /> f.1 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing_ f Specifications <br /> I'I Public C7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done C Type of Pump H.P. State Work Donee <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth y Filler Material & Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is <br /> y available within 200 feet.) <br /> 4.___.__,)nstallation will serve: Residence'_'Commercial_ Other l <br /> Number of living units: Number of bedrooms <br /> • i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg' Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ `t Method•of.Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS AL1 Distance to nearest: Well Foundation Property Line 'h <br /> w <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 Joaquin County .11 4 <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 subcontracting 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 td workman's compensa- <br /> tion laws of California." <br /> i <br /> Thea 6nt m sl call f r a r red inspections. Complete drawing on reverse side. <br /> Signed Title: rporate Secretary Date: 2/2/93 <br /> FOR DEPARTMENT USE ONLY <br /> 1 7S <br /> Application Accepted by Qyoc"s kAc x;�-• - - - Data �3— Area d ?_AA----- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Coun y Public Health Services pl� T <br /> Environmental Health Permit/Services �t 7 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1� fl `,, r. f��5/�3. <br /> FEE AMOUNT DUE AMOUNT REMITTED I CASE RECEIVED BY DATE L( iTPERMII[1't^NO. (' <br /> INFO <br /> . EH 13.241REV.riMs� \A1 1) jry�f 'Q ('rte. cis J T< �^�� 11177� ,0 11 <br /> EH 14.26 r� a ii <br />