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it <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 1�6042 E. Baker Lane City Linden Lot Size/Acreage <br /> Lagomarsino Address 16042 E. Baker, Linden — Phone <br /> Owner's Name <br /> i <br /> ContractPurviance Drilles,IAOress .-P.O. Box 64�Linden�JcGe No. 377923 Phone - <br /> TYPE OF WELL/PUMP: NEW WELD] - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ] Open Bottom ❑ Manteca Dia. of Well Excavation 19 Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of;Casing_ d Specifications <br /> I1 Public. Cl Other (1 Delta Depth of,Grout Seat r 0, Type of Grout r gUl,-_ :L <br /> t�t Irrigation 111 Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of PumpTurh H.p. 40:: State Work Done _ 4- <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth _ <br /> Depth Filler Material& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION L I 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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> :Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ -No. & Length of lines Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth _. Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 /> t Home owner or licensed agent's signature certifies the following: 'Tcertify 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." <br />! The plicant m t call,f req re inspections. Complete drawing on reverse side. <br /> Signed Ks _ Title: _Corp Serrrim tary Date: z/ 94Q <br /> 1- FOR DEPARTMENT USE ONLY c� q <br /> 4 Application Accepted by `^� ��ae.e, ,x. Date `^ ,�{Z— Area t <br /> I Pit or Grout spection by Date , Final Inspection by Data 1 - <br />' Additional Comments: ", <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services / fV&,, <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I <br /> t FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT'NO. <br /> i INFO CASH <br /> 1 <br /> . EH 13.2 (REV. i x 7'�2. <br /> 51 y N (� s t®® 7 <br /> EH t4•20 <br />