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APPLICATION <br /> SAN ."OAQUIN COUNTY PUBLIC <br /> SLRV ICES <br /> ENVIRONMENTAL HEALTON_ <br /> 445 N SAN JOAQUIN, PHON8-342 �— <br /> P O BOX 2009, STOCKTPERMIT EXPIRES 1 YEAR F <br /> (Complete in Trip i9W <br /> Application is hereby made to San Joaquin County for a permit to constr a vor ere n described. This <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 9948 Harlan Rd CityFrench Camp Lot Size/Acreage23 Arrps <br /> Caterina Fredrick 94123 <br /> Owner's Name Address 1976 Lombard San Franciarn Phone (41 SS931-0572 <br /> Contractor Pueketts Pomp & WellAddress P. 0. Box 602 Linden 95236License No.521666 Phone 944-5969 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> qLl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> {"I Public Cl Other P Delta Depth of Grout Seal Type of Grout <br /> ii IolgaCion _Approx. De ih I I Eastern ��77 S))u�rface Seal Installed by <br /> Repair Work Done R9. Type of Pump H.P. _il__MP-- State Work Done <br /> Well Destruction ❑ Well Diameter <br /> r/ Sealing Material i Depth <br /> Depth Sol Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of wil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE No. 8 Length of lines Total length/size <br /> FILTER BED CI tante to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L.1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance 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, I shall 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion laws of California." <br /> The applicant call for all r it ins p s. Complete drawing on reverse side. <br /> Contractor 1-15-94 <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY i, z4-/°o- <br /> Application Accepted by W"nDate A <br /> Pit or Grout Inspection by Date Final Inspection by j- 2 �� 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, Stkn, CA 95201 <br /> LyFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER M17 <br /> 30 INFO N0. <br /> fR ;3 24 rrxsr U� l <br />