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> �� �• gid.*..��. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQU IN, PHONE (209)468-3420 <br /> `.K ` P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> M. y 4 -(Complete Complete in Triplicate) O '-7 — q(0—Z Q <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 Co bl h ervi <br /> CSl , , ' E. of Gettysburg <br /> Job Address <br /> Place & 1001 N of Ben. Hol ter.__— city StOrlrt On_ Lot Size/Acreage <br /> County of San Joaquin <br /> Owner's Name Deft • f P dress <br /> Phone - <br /> 3620 Chestnut Ave 639090 Phone 510-687-90 <br /> Contractor Dia '10 t�m CO _Address License No. T <br /> j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT P DESTRUCTION [X out of service We.1.1 <br /> Monitoring Well n <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? <br /> C1 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Vg <br /> C.l <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ��.... <br /> Il Public l-1 Other I"1 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 ❑ Type of Pump H.P. State Work Done Q 1 <br /> Well Destruction Well Diameter <br /> 121.1 sealing Material & Depth cement <br /> ! 1871 Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I Molise ttic tin system emitted if public sewer is C f <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet. Water table riepih,. (�� <br /> SEPTIC TANK. ❑ Type/Mfg Capacity m <br /> No. Compartents <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line + ' <br /> LEACHING LINE L-1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distancetonearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distanceito nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> t 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: "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 applicant mus to all equirec ctions. Complete drawing on reverse side. <br /> 19 92 <br /> Signed X <br /> Title: Date' <br /> FO EPARTMENT USE ONLY <br /> I <br /> Application Accepted by Date r' 1� Area <br /> Pit or Grout Inspection by <br /> Date Final inspection by w� <br /> Additional Comments: w <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> j 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> CK <br /> i f <br /> t <br /> IW <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT NO. <br /> C� Z 34 <br />