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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRO.r AL HEALTH DIVISION <br /> 1601 E HAZELT�ON AVE, PHONE (209)68-3420 PAYMENT <br /> P O BOX 2009, STOCHTON, CA 95201 RECEIVED <br /> PERMIT_MPIRF3f,S 1 YEAR FROM DP,,TS ISSUED APR 5 1990 <br /> (Complete in Triplicate) sghi J0a01:Ihv<.::O„?.l1y <br /> Application is hereby ade,to San Joaquin County for a permit to construct and/or install � C 4 r�ei3rC i� y This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and ttal� 'aTtitid�l6t n <br /> Joaquin County Public <br /> 11,,dth� )Services. /�}� yt <br /> { Job Addfesa � i/y°C� ,� ,�1-7c !'(J/ City rTG Lot Size/Acreage e <br /> Owner's Name .Ta_e— &;V'f Z Address 26 (A*57-_54 LL=TE 6U) Phone 23S 09 <br /> ' Co2iCe rd <br /> Contractor Kol�ltvv G ( QYAk1 Address rlv r_LN,04--AI4T_)_N _ CA License No. Ao PRpn��'gs <br /> TYPE OF WELL/PUM : NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4R6 gp3,T',15 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES DISPOSAL FLU.— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Wail Excavation Dia. of Well Casing <br /> fl OomesticlPrivate 0 Gravel Pack 17 Tracy Type of Casing Specifications. <br /> I'1 Public f:l Other fl Delta Depth of Grout Seal -30 r Type of Grout &k%,'CCnvcrt; ' <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.A. State Work Done_ <br /> I Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> i <br /> i Depth Piller Material k Depth �] <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feat.l <br /> Installation will serve: Residence— Commercial_____ Other <br /> Number of living units: Number of bedrooms <br /> t. <br /> I Character of$oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 <br /> Method of Disposal <br />` Distance to nearest: Well Foundation Property Trine <br /> LEACHING LINE Cl No. &Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I - Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation�__ __, Property Line <br /> DISPOSAL PONDS 0 <br />€^ ! i hereby certify that I have prepared this application and that the work Witt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Nome 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 /> certifier:the following;"I Certify that in the performance of the work for which this permit is issued,I ahali employ persons subject to workman's compensa- <br /> tion laws of Californl ' <br /> The applic II forqu'ed Ins ions. Complete drawing on reverse side. <br /> Sign Title: Date: �f <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date 0 Area <br /> Pit at Grout Inspection by Date Final Inspection by Date /� 0 <br /> E <br />` Additional Comments: <br /> Applicant - Return all copies to: Sou Joaquin County Public Health 1 <br /> Services, EavironmentAl Health Permit/Services <br /> 1601 E. Hazelton Ave„ P 0 Boa 2009. Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CAeH <br /> RECEIVED BY DATE PERMIT NO. <br /> , <br /> . EM 1}24 MtV.deer - eehh l f/ +i <br /> tEH'i1.2a� V�.f.r7 f •� tl d—a Lt4S' <br />