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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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 rade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San ! <br /> Joaquin County Public Health Services. <br /> Job Address S 9 5 0 E U!n O d b r i-d_c_P. Rd - City _Ara,-_ mY p n Lot Size/Acreage <br /> Owner's Name ROBERT MONDAY1 WINERYddress a r Phone <br /> P .O.Box 113 <br /> Contractor GOEHRING PUMP Address Lockeford . CA License No,_3D9 03-1—Phone 7 7.7- <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT 17 DESTRUCTION Cl Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> -INTENDED USE­ - ,.TYPE-O_-WELL- _PROBLEM AREA,C_ON_STRUCTIOP S_PE_CIFiCA_TIO <br /> . NS <br /> Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca <br /> Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_ Specifications j <br /> Il Public C7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irfigation _,Approx. Depth, II I Eastern S'uace Seal installed by <br /> Repair Work Done 0 Type of Pump Sub r H.P. �/� State Work Done.4:h a n rr e 3 r r h p r k V a I e <br /> Well Destruction 0 Well Diameter Sealing.Material & Depth Oj <br /> Depth - Filler Material_& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/AODIT'ION 1 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg - = ;Capacity No. `P* rME <br /> PKG. TREATMENT PLT. ❑ ED <br /> - Meth yj <br /> Distance to nearest: Well Foundation Property Line <br /> -. 93 -v_ <br /> LEACHING LINE Cl No. & Length of lines e:~. Total length/si <br /> FILTER BED Cl Distance to nearest: Well Foundation Prop e.�ERVICES <br /> ENVIRONMENT AL HEALTH DIVISION <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS 1:1 Distance to nearest: Well Foundation Property Line <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 count ordinances, state_laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed ape 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 ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: " 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 Califomi . <br /> The applicant mus all I uired inspections. Complete drawing on reverse side. <br /> Signed X Title: Data. 47 /f)3-/q -- --- <br /> FOR DEPARTMENT USE ONLY 1,, <br /> Application Accepted by ? _ ,®cam Date " Z Area 7— <br /> Pit <br /> Pit or Grout Inspection by Date Final Inspection by <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 REMITTEO CK 9 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 17.24 IREV.t, w i-� <br /> EH 14•2e ir <br />