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APPLICATION FOR PERMIT ,-, f <br /> SAH :AQUIN COUNTY PUBLIC HEALTH4RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 Bog 2009, STOCKTON t� CA 95201 PAYMENT <br /> REMIT IRE VVAD VDnu. D RECEIVE® <br /> (Complete in Triplicate) APR 2 7 1993 <br /> Application to hereby rude to Sen Joaquin County for a permit to construct and/or install the v �� OUNTY <br /> aPplieation is wade to ec4lianee with Ban Joaquin County Ordinance No. 544 and i862 and the lCr9s <br /> Joaquin Coanty Pub a Health rvicee. ENVIRON � MilfiftON <br /> 1 std. 1( ` <br /> Job Addrea City Stockton Lot Size/Acreage - approx 5 acres <br /> 1 <br /> Owner's Name Custom Food .Machneld,e„ 1 881 E. Market Street <br /> ph" 209-463.-4343 <br /> Contractor Osteburg & Stewar)iddress 2601 River Road Myd9-§&Qe No. 446670 phone 524-3852 <br /> ' TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION Cl Out of Service well ❑ <br /> I <br /> 1 PUMP INSTALLJITION ❑ SYSTEM REPAIR C1 OTHER OR Monitoring Well .❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 00 SEWER LINES 100!I DISPOSAL FLO. pROp l Baring <br /> !i FOUNDATION 1 (ems— AGRICULTURE WELL .q,. A—I OTHER WELL _._..PITS/SUM PS U4A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Soil Boring <br /> CI Industrial O Open Bottom ❑ Manteca Dia, of WsII Excavation Dia. of Weil Casing <br /> r <br /> 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 11 Spedfksibns 44 <br /> I'1 Public I:1 Other 1'1 Delta Depth of Grout Seal Type of Grout F <br /> I I Irrloslkm Approa. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. 11 State Work Done_ <br /> WON Destruction O We"Diameter Sealing Material i Depth ~' <br />'I Depth Filler Material i Depth <br /> i 1 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION 1 1 �n(No septic system permitted if public sower is V ' <br /> avaRoble within 200 lost.1 <br /> Installation vein serve: Residence— Commerclel_ Other <br /> Number untie: Number of bedroom <br /> Character of soil to a of S feet.. �tsbkdtmpth " <br /> SEPTIC TANK. 0 T Capscl No. Compartments <br /> .PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Foundation _-- -- Property Line <br /> LEACHING LINE Cl No. A Length of ! Total lengthhlre <br /> FILTER SED ❑ Dletana t rest: Well— __ Foundation ._ Property Line <br /> SEEPAGE PITS I th Site Number } <br /> SUMPS LI Distance to nearest: Wall Foundation !� Property Lk» <br /> DISPOSAL P LS ❑ <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 ilgnature certifies the following: "I certify that In the perform ante of the work for which this permit is issued, I shah not p <br /> employ any person In much manner as to become subject to workman s compensation laws of California.' Contractor's hiring or sub-contracting signature <br /> certlfles the following: "l artily that in the performance of the work for which this permit is Issued,I ahsli employ persons subject to workmen's cornpenst. <br /> tion laws of Canfornle", ! <br /> The appFkaM at call for Mad ins kens. Complete drawing on reverse side. See Attached drawing <br /> signed Title: i Technical. Services Dale; April 1 ,1 993 <br /> !I i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date - —3) Arae <br /> Pit or Grout If Won by Date J 2 9 Find Inspection by Data l <br /> Addhkmel Continents: i <br /> Applicant - tteturn all copies to: Sae Joaquin County Public Health Services <br /> s°b nVA- <br /> Environmental Health Permit/Services ! <br /> 445 N San Joaquin, P 0 Box 2009 Stkn, QA 95201FEE �� f <br /> J , <br /> INFO AMOUNT DUE AMOUNT AEMITTEO CASHRECEiVEO 0Y DATE PIpMIT'NO. <br /> II' <br />