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�./ APPLICATION FOR PERMIT :: <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUER <br /> (Complete in Triplicate) <br /> Application is hereby ands.to Baa Joaquin County for a Permit to construct and/or install the vork herein described. This <br /> application is ends to compliance vith Baa Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 4491 W. DUrhoM Ferry Road Cit. Tracy cot Site/Acreage 0.75 acres <br /> any, CA <br /> Owner's Name Ms. Stella Ruiz Addrea 4491 W. Durham Ferry Road Phone 209-835-7554 <br /> o ave, <br /> Contractor West Hazmat i1lir%dress 3233 Fitzgerald License No. 554979 Phone 916-638-727 <br /> PE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Wall Lq <br /> DISTANCE TO NEAREST: SEPTIC TANK135'— SEWER LINES DISPOSAL FLO._0 PROP. LINE 10 <br /> FOUNDATION 10 AGRICULTURE WELL OTHER WELL 75 PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industria O Open Bottom O Manteca Dis. of Well Excavation Dia. of Well Casing n <br /> *Domestic/Private IN Grew) Pack M Trac. Type of Casing PVC Specifications <br /> D Public 1:1 Other O Delta Depth of Grout Seal flPL1rOX 13' Type of Grout <br /> M Irrigation .Approx. Depth ❑ Eastern SuAice Seal Installed by Wet Hamnat�Tlri l incl <br /> Repair Work Done D TV"of Pump ,0 M.P. Stan Work Done_ <br /> wooDearuet)on o Well Diameter '2 Sealing Material i Depth V tl,i rk, }mentrmi tp 15 <br /> Depth 30' Piller Material A Depth Cement anorex. 13' -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION o REPAIR/ADOITION M DESTRUCTION 0 INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living unke: Number of bedrooms <br /> Character of sol to a depth of 3 fes: Water table depth <br /> SEPTIC TANK_ O Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT.o Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE o No. & Length of Mmes Total length/sixe 3 <br /> FILTER BED ❑ Distance to newest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth _Sia* Number NI <br /> SUMPS Ll Distance to newest: WellFoundation Property Lite <br /> DISPOSAL PONOS o <br /> litsnby cwWv that 1 have prepared this application and that the work will be done in aeeordone*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.1 shelf 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 /> owiffiN the following:"I certify that in the performance of the work for which this permit is issued.I ahs#employ persons subject to workman's compensa- <br /> tion Wes of Calfomla." <br /> The appYeMtt must sag for all quNed W4 <br /> yeptions. Complete drawing on reverse side.�/y{ <br /> Signal X�/✓ Title: =e e-4- AAA)j14 Date: <br /> P ENT USE ONLY �3 <br /> Application Accepted by �! 'G�''�—. Date. - 9/ Ates <br /> Pit or Oma Inspection by Date Final Inspection by pate <br /> Additional Cowatema: <br /> Applicant - Return all copies to: SAH JOAQuix COUNTY PUBLIC MMTH BHRVICHB <br /> MIVIRONYHNTAL MULTH DIVISION PHRNIT/SRRVICHS <br /> 448 N BAN JOAQUIN, P 0 BOX 2000, BTOCXTON, CA 08201 <br /> Moro AMOUNT DUE AMOUNT REMITTED CASH/ RECEIVED BY DATE [ PERMIT.'fNo. <br /> . fJ13-24 IaN.�r+am $—\� Ue—00 <br /> fN:4xe _J <br />