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.ems <br /> •� ~CAas <br /> SANOAQUINGOOKY1 ,PUBLIC HEALTH SERVICES <br /> =VIAL HEALTH DIVISION <br /> 44XJ ly <br /> 5 N SAN JOAQtTIN, PHONE {209)488-342 <br /> P O HOZ 2009, STOC.E' ON, CA 95202 <br /> 2MIT BBPJBES , •YEAR- SATE .ISSUED <br /> (Complete in Triplicate) MAR 2 2 1994 <br /> Application is hereby sade•to Baa JoaQuta County for a�*perstit.to construct and/or instill This <br /> application is made in coso3"We with Ban Joaquin County Ordinance, Mo..5WAmd 1862 and of,-San <br /> Joaquin County Public Health Services. <br /> Job AddreM Lot'Size/Acreage <br /> es ar rtg: . �� <br /> Address Phone -9--16--) <br /> ---- <br /> Ow •a Name <br /> S `(� 3241 F• t�g�ald Rd. , #2 <br /> Conic ' T11 oA d` r xatfaessCho Cordova 95�4�icense No,b62720 Phar 916 .X52� 54 <br /> TYPE <br /> WEVY <br /> LL/PUMP: NEW, EL 0- WELL,REPt ACEWNT n DESTRUCTION O Out o Service Hell, <br /> PUMP INSTALLATION O SYSTEM REPAIR L OTHER D MMitoritlg Well <br /> DISTANCE TO NEAREST: SEPTIC TANK N SEVOOWLiNES30 r � DISPOSAL FLO. N/APROP. LINE r <br /> FOUNDATION . AGRICULTURE WELL'-&—A r A OTHER WELL N/A PITS/SUMPS N� <br /> INTENDED USE TYPE OF WELL ' 0008LEM AREA CONSTRUCTION SPECIFICATIONS <br /> LI'Industrial O Open Bottom O'Manteca Dia.of%444 Excavation Dia. of Well " ' <br /> Citltttg <br /> IX DommiciPrivam Gr"Pack L7:Taticy Type 0cssing_�PVC SCh, 40 Specificatiaa <br /> Il Public CI Ottler 11 Delta Depth of Grout Seal • 41 t Type of GrypOrtle"Ild- a nt <br /> by flush grey well <br /> _ er, <br /> I I Irrala tion __ Approx. Depth ItEastern Surface Sial Iinstalledca'�..,. <br /> Repair Work Done U Type of PumpN.P. ;State Work Dort* <br /> Well Destruction O We# Diameter 211 + 8aalLr4 Nsterial i Depth hentba,j to.. 41-A <br /> Depth fYller Material • Depth m2nnt e.:E2 y.s and 43= -601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 RE !ADDITION I I DESTRUCTIQN-1 14 acetic system permitted it tar suer is <br /> available within 200 f <br /> Inst : Residence_ ContntareW— Other <br /> NurtMrrzNvinQ unds Nuertbor of bedroo s <br /> Character of sole to a depth of 3 Water table depth <br /> SEPTIC-TANK O Type/Mfg Capacity No. Compartm rna <br /> PKG. TREAIENT PLT.Q Method of Disposal <br /> Distance to newest: all etion Property Line <br /> LEACHNrG UNE L1 No. tit of litres T@ts !size <br /> FILTER BED t <br /> is <br /> to naaretC Woo Fourtuatwn Prop*ny <br /> SEEPAGE 11 Depth Size Number <br /> SUMP LI Distance to room t: Wall Foundation Property Lin* <br /> DISPOSAL PONDS- D <br /> 1 hereby o0ft that I haw prepared this application and that the work will be done in accordance with tan Joaquin county ordinances,state laws, and <br /> rubs and regulations of the San Joaquin•County <br /> Home owner or licensed*Vent's signature candies the following: "I certify,that in the pwiwmance of the work for which this permit is issued. 1 shell not <br /> employ 9fty'0ereon in such martrter as to become subject W wo kmsn's compensation laws of California."Contractor's hiring or sub-contriattg sipnaWq <br /> oatifiss the 100owing:"I certify that in the performance of the work for which this permit is issued,1 shalt employ persons subject to worhman's.compsflsa- <br /> tion Tawe.W CNIOrrtle.-" <br /> The.applicant C <br /> required' Complete drawing on r*V fflo s s;.., <br /> x <br /> signed X Title: PrOjegy PWager Date: 3-22-94 <br /> FOR D11PARTMENIT U ONL1 <br /> Application Accepted by Oats _ L__.Ana <br /> Pit or Grout Inspection by AATLAhkaDate 3 Final Inspection by 4&e= Data <br /> Additional Comments: <br /> Applicant - Return all copies to: Sea Joaquin County public Sealtb Services <br /> Suvlrotaaental Health Perait:/services s� <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DIJE AMOUNT REMITTEDCK <br /> CA I RECEIVED BY DATE PERMIT'NO. <br /> . Em1i34thev.Iiest LO�, - 00 .,. - IX5 <br />