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MAY 05 '95 09:310M ANDERSON CONSULT INGPLI CATION <br /> SAN400AQUiN COUNTY PUBLIC HEALTH RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PX MIT EXPIRES I YEA-. FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Apyilcetios is hereby bede,te San Joaquin Coupty for a peraf.t to eebetruct Aad/or loetall the vorx herein described, Tbie <br /> application in aide in coapli"ce vlth Sen Jaequin COouty Ordinapee go. 549 and 16Q ervi the Rules and Ref;QAtions of Est, <br /> ]crquir, enunty Pudic Health Services. <br /> �a s�. eA f--F 1 a V- City ' Lot Slu/Aereagc 0,27 61 Cr e- <br /> Job Address _ <br /> Ownar'll Name �rY n I f�Cl P_ .. Address 5 • w I r 1 <br /> Phone <br /> rn�q�[► ``✓•r r <br /> P r— 17 ` �nmelPFre nr•i dPr R4�'eP�/ .�v f Ph01121 7 <br /> DIXIIfatLar +�µt `� nsa��f AddressOlLicense NoJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Scrvlcc Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER6%_S Coring Well 171DISTANCE TO NEAREST: SEPTIC TANK —.�. SEWER LINES DISPOSAL FLO. PROP.��N _ pO V <br /> FOUNDATION AGRICULTVRE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll IndUstriel ❑ Gpen Bottom L] Manteca Du- of Well Escavatinn Dia. of Welt Casing <br /> Cl nomeet1CIPrivale 0 Gravel Pack7 ❑ Tracy Type of Casing—. SpeOh"B110"i <br /> I'I Pnbtic 171014, fl Delta Depth of Grout Seal Type of <br /> I I Inigalkw —approx Depth 1 1 Easum Surface Sed fnualled by — - <br /> Repair Work Done ❑ Typs of Punrp N.P. State Work Done — <br /> Wag OMtrucum ❑ Well Diameter Sealing Material A Depth y _ f <br /> Dep,n f r- s b Filler Waurxat. A naprt, e2 ent 5 tarry <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIRIADDITION 1 I DESTRUCTION 111No wplic system permitted if public sower ie <br /> available within 200 feat-I <br /> Imlaeadun will carve: Rasidenoa Commercial_ Other <br /> Number of living nnitC Number of bedrooms <br /> Gharaeler of sell TO•depth of 3 het: Water table depth <br /> SEPTIC TANK ❑ TypelMfg — Capacity No. Computments <br /> PKG. TREATMENT PLT.0 Mashm of Disposal <br /> Gislance to nasi Weil Foundation Properly Lina <br /> LEACHING LINE U No. 6 I trrpth of lines Tolaf length/size <br /> FILTER BED ❑ Distance to nearest: Well Foutmeddn Property Lina <br /> SEEPAGE PITS I 1 Depth __. Size Number <br /> SUMPS LI Oistanca W nearest: well Foundation _. Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I hate prepared Ihi6 application end that the work will he done In accordance with San Joaquin oounly ordinances, slam laws. and <br /> NMB end regulelimla of the San Jo"Lin County <br /> Home owner or licensed agent a w9naltae certAas the followinil: •'I Certify that in the pednrmence of the work for Which this permit is issued. I shell not <br /> employ any person in such manner as to became subject to workman's compensation lame of California." Conneeto's hiring or sub-eonlyacttng signature <br /> rattif,iaa the following:"T certify that in the pariamaerlee of the work for which this permit is issued, I ehall employ persons subject toworkmAn's chmperlsA- <br /> tion Isar of Celifomis:' <br /> The applira t for so rod ns[lections. Complete*awing on reverse side_,1,s <br /> Signed);Jyd .. .�.._.. Title: 4edDate: <br /> FOR DEPARTMENT USE ONLY <br /> Appligetion Accepted by Dave Area <br /> Ph or Gant Impeotian by Date Final Inspection by Date <br /> Additional Cornmaotr <br /> Applicant — Retura all cople� to: San Joapule county Public Health Services <br /> Euvironmental Health Fernitlaervicee <br /> 445 N Sae Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEBCK <br /> AMOUNT DUE AMOUNT REMITTED CASH PECEIVEp aY DATE PERMIT NO. <br /> NFO <br /> • EH 1131[PEY.I/au <br /> FN 1a•>D <br />