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Jilrvj <br /> . IN COUNTY PUBLIC HEALTH SF ' CE <br /> SAN k <br /> I RONiI�ENTAL HEALTH ID I V I S I ON <br /> k <br /> SAN JOA UiN- PHONE (209)4683420 <br /> 445 N p 0 BO% 9009.r STOCgTON, CA 95201 <br /> �.� .' APR 13 1993 <br /> a u <br /> R <br /> tiIT r%PiR�S ]YTSAR: M <br /> D <br /> F O ATE ISS ED . <br /> (Compltyte in, Triplicate) ENVII2pIViV1i'VfALHEA� <br /> • Tl l <br /> ' ,�, g This <br /> Application 1i hereby. iAde to Sae :Joaquin County for s permit to eenstruct: and/or instili the work t�&2M1T.V6R14�6E <br /> spplication is Madb ila'.jcerapiianes irith San Joa4uib County brdirAnce No. 540 6.nd 1869 i1nd the Rules and Ae&]Ations o3 San <br /> Josquio County Public Health Services. <br /> ,';,5 ✓ �.!!(J City 7U►'1 Lot 3izelAcrei3igeQr -- _ <br /> Job Address :Stat 3168 <br /> /Zoo-91" <br /> 4Q f�s Addiasi f�+tf? 'r — Phone O <br /> Owner'a Name t r r <br /> - <br /> C740 <br /> Iif�t7 f` ddress :da1KL fa License No,.S�1b 33t+ori 0 D i !� <br /> Contractor / <br /> TYPE Of WELL/PUMP: 'f'i NEW WELL WELL REPLACEMENT ❑ , DESTRUCTION L1 Out of Service well ❑ Vl <br /> PUMP INSTALLA7tL7 SYSTEM RE R 1:1 <br /> OTHER ❑ < monitoring Well <br />` DISTANCE TO NEAREST:€iSEPtIC TANK SEWEFI LINES �� DISPOSAL F6D.' PROP: LINE • �j <br /> FOUNDATION LZs� _ AGRICULTURE WELL, �/A OTHER WELL PITS/SUMPS 11"1 k <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial ° O Open Bottom Manteca Dia, 01 Well Eitcavation <br /> Dia..of Welt Caain�' <br /> Type of Caging_ r'rC f Specilrcation4 <br /> 0 Domestic/Private Ll Gravel Pic;. ❑ Traey T <br /> I"}'Publie 'D�br a f 1 Delia' Dbpth o!,Grout Seal �' type of Giout V, <br /> r <br /> I i Irrigation ,$i:�``,6� Appros, Depih l I Eastern Surface Seal lnstslled by r , i <br /> Repair Work Done V Typs of Pump H.P. 1' Steib Wdrk done <br /> t '., Reeling Wteriel i Depth <br /> Well Destruction D Well ojametet — . <br /> Depth P'i11ei• )Uterlal i nept � <br /> TYPE OF SEPTIC WORK: ;j NEW INSTALLATION l I . REPAIRIADDITION I I -DESTRUCTION I I Imo septic sysadm permitted it public sewer is <br /> t <br /> available within 300 fedt.1 <br /> Installation will -serve: gsaidence Comihistcial__.w... Othei_ I <br /> Number of living units: '` Number' of bedrooms " <br /> Water tibta depih <br /> Character of toll to a imp,ill of 3 (eat: <br /> r <br /> l <br /> SEPTIC TANK b Type/Mfg Ci4pacitY No. Compartments ' <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest- Well - Foundation Property i Gia? <br /> LEACHING LINE . 0 No. b Length of linei Total length/site <br /> FILTER BED j tD Distancb to nearest: <br /> Well Foiindetion Ptoperiy Line I <br /> SEEPAGE PITS I l oapih Size Number I <br /> SUMPS L1 Distance to nearest: Well Foundation Property Lins <br /> DISPOSAL PONDS a C7 `i l <br /> I hereby certify that I hivii 06*6dl ihls Application and that ths'work will be done in accordance with San Joaquin county ordinan6fiC stets lawn, and <br /> rules and mdulationi of the San Joaquin County: v <br /> Home owner of fleahw sbent's•signature Certifieit the following: ''1 ebrtify tkat in the perforrnarici of the work for which this piiinit li issued, I thea not <br /> employ any parson in ssitfi inch tdr as tb bbtorits WNW to workman's C0610snsation laws bf Cilift)AW"Contractor's hiiing or sub-contracting signature ll hh <br /> eertifies the following:"I sanity that in fhb oirlormance of the work foi which this permit 1a iieuiid,I'$hall iniptoy persons subject to workman's compensa- <br /> tion laws of Csllfomli." �! ? <br /> The applicant must all'foi Q1 to id inipsc66m. Complete drawing on roveiiia!id`s ' P <br /> S r� e ► Date: l z` j y <br /> Signed Title: f7�' ti 0 G - — <br /> s ' i,. <br /> " FOR DEPARTMENT�USEONLY <br /> Application Accepted by f,..:, Dit6 34 X '.Aron! <br /> Date Fin npaotl by r <br /> . it I on . .. ' <br /> Pit or Grout Inspectlnn by ! '' �` � � - - - I <br /> Mite <br /> Additional Comments: <br /> Applicant - fibtdr,n all copies to: San Joaquid County.Pubiic Health Services ��77GIOQ <br /> s Environmental health Permit/Services <br /> 445 N Sun Joaquin; .P 0 Boit 2009, Stith, CA 95201 <br /> FEE AMOUNT DtJE AMOUNT REMITTED CASH ; .. RECEIVE$) BY DATE <br /> INFO 'ALA <br /> to1344Otkv.l,esl <br /> - <br />