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APPLICdTION <br /> J►a�� �l��(( JVD+ ..� <br /> SAN JOAQUIN COUNTY PUBLIC HF:AT.TH SERVICES <br /> zSV I RONMENTAL HEALTH DIVISION <br /> DEC 0 81994 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ENVIRONMENTAL HEALTH '� -�, <br /> PERMIUSERVICES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a per--,t to construct and/or install the vor)L herein described. Th <br /> appllcatlon is made in ccc:Pllance with Sam Joaquin County Ordln&nce No. 549 and 1862 and the Rules and Regulations of Sa <br /> Joaua <br /> quin Coty Public Health Seryces. <br /> Job Address N ^u &I JI! f-- <br /> n Lot Size/Acreage <br /> Owner's Name A:A(c �rxt�C� 5 l . k0-�`��t Address 2000Alf'll"L-dz �a'� <br /> Phone��tS -71-ZqE' <br /> Cr.. G{ 4,-fOz- <br /> Contractor�u�N 5)-t -a-�t;v.. Address �7 ,,cam f-- � .('-C{�-I:i> License No C �� Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ,lfatNlr,�T ER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf "pig ASAI FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> %�•t i 4— ❑ Open Bottom ❑ Manteca Dia. of Well E:cavatan 1 <br /> N Domestic/Private Gravel Pack• Oia. of Well Casing <br /> ❑ Tracy Type of Casing_PVL SGI, ltd Specifications <br /> 1'1 Public 'I.1 Other Delta Oepth of Grout Seal %0y-'�-Z- i Type at Grout CU4�^�1 bz <br /> I I frnUatpn Approx. Depth I I Eastern Surface Soul Installed by ~ <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Wolf OesMretion O WON Oianwter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF'I-EPTIC WORK. NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I Ileoseptic system permitted it public sower is <br /> available within 200 feet.l <br /> Installetwill verve. idence_ Commercial_ Other <br /> Number of living units: bar of bedrooms <br /> Character of soil to•depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK O Type/Mf9 Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal <br /> Distance to nearest: We11 Fou an Property Line <br /> LEACHING LINE ❑ No. 6 Length of linea To ngih/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Pro Line <br /> SEEPAGE PITS If Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONOS O <br /> I hereby certify that I hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ar <br /> rules and regulio <br /> atns 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 tot which this permit is issued. I shall n <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signatu <br /> certifies the fo4owing:"I certify that in the performance of the work for which this permit i <br /> tion laws of Califomia." s issued,I shall employ parsons subleet to workmen'sa compenZ"j5f2)::�&!U-*`v2X <br /> The applicant must uN for all required inspComdo. <br /> signal Tale: c.4- 6e%-Jeer t'114- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <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, Stites, CA 95201 <br /> FEE AMOUNT DUE AMOUNTREMITTED CK <br /> INFO CASH RECEIVED 8Y OATE PERMIT.NO. <br /> • Ea:124(REV.ir•si <br /> Eh ts•as <br />