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APPLICATION <br /> SAN*'AQuifi COUNTY PUBLIC HEALTH�&BVICES <br /> BNVIBOiiil[ffi1TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (Complete in Triplicate)ote:iFor three monitoring <br /> wells <br /> Application is hereby made,to San Joaquin County for a permit to construct aodJortanvoic <br /> rr lye in ram bled'.--phis <br /> application is made in dcaplianae with San Joaquin county Ordinance No. Sag and 1862 and the Rules and Resalations of San <br /> Joaquin county Public Health Services. <br /> 1740 Houston Avenue City Stockton Lot Size/Acresae170.8 acre colf <br /> Job Address Odle <br /> Owner's Name Addrass Phone <br /> 4230 Kiernan Ave.r No. 105 <br /> Contracts The Twining Modesto, Chi 95356 License No 057506159 Pha M9-545"1050 <br /> TYPE OF WELL/PUMP: NEW WELL $1 WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Wall LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring WallQ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1E DISPOSAL FLD.lM'CW PROP. UNE100' S <br /> FOUNDATION _2' AGRICULTURE WELL>2,WOWOTHER WELIM'M— PITS/SU PSOQ!-M WXjca <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Walt Excavation Dia. of Wall Cseinp <br /> n Domestic/Private Q Gravel Pack ❑ Tracy Type of Coming S11131w19 r 2D IM Specifics <br /> I'1 Public n Other 1(1 Delta Depth of Grout Seal 6 Type of <br /> I I Irrigation 30L Approx. Depth I I Eastern Surface Seal Installed by w.13.%l'vIF"�+e <br /> Repair Work Done U Two of Pump n/a ,^ H.P.-ala Sim Work Dons <br /> Wei Destruction O WON Diameter i*rh Sealing ilateri.al A Depth <br /> Depth r 30 fsaa- Pillar Material ti Depth fmB 2-6' \ <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> availeble within 2W few.) <br /> Ing"Osdon will servo: Reeidanaa— Commercial_ Other <br /> Number of Nvinq units: Number of bedrooms <br /> Character of soil to a depth of 3 feat: Water table de0th <br /> SEPTIC TANK O Typo/Mfg Coped NoComporunents <br /> . <br /> TREATMENT PLT.O Method of Dial <br /> Distance to nearest: Well Foundation Property Lino <br /> LEACHING UNE n No. 8 Length of lines Total Nngth/size <br /> FILTER BED O Distance to noemst: WON Foundation Property Lina <br /> SEEPAGE PITS I I DOWN Sire Numbs <br /> SUMPS LI Distance to nearmt: Well Foundation Property Lina <br /> DISPOSAL PONDS O <br /> 1 hereby earthy that I hats prepared this application and that the work will be done in accordance with San Joaquin county ordinances.state leas. and <br /> runts and ragulations of the San Joaquin county <br /> Homs owner or licensed agant's signature cartiMs the following: "I certify that in the performance of the work for which this permit is issued. i shah not <br /> employ any parson in such nwnnar as to become subject to workman's compensation laws of California."Contractors hiring or sub•conftcting signature <br /> cerWas the following:"I certify that in the performance of the work for which this permit is issued,I shall unploy POMMIS 0410 to w0d~'s Gnmparlw- <br /> dorn laws at California." <br /> The applicant must call for all reqWed inspections. Complete drawing on eras aids. <br /> Signedrte; 1/:e;/w;f 1 Wta: . S G <br /> R DEPAM MEEN�T U99 ONLY <br /> Application Accepted by Dna7 I Ana <br /> Pk or Grout Irwpaction by <br /> Date Final Inspection by Data <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Bavironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2000, Btkn, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED f�SH I RECEIVED By DATE PeRM17'No. <br /> . M 13.24 IREV.1/ 61 WAT /T — <br /> EM 14-M V <br />