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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 1 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is 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 21500 H A N S E N R D. /A P N 209-190­2-7. City TRACY Lot Size/Acreage <br /> Owner's Name E D L U S B Y Address 3580 EAST AVE H Phone (510) 886-3609 <br /> ' Contractor HENNINGS BROS. DRILL.Address 3525 PELANDALE AVE License No._2_9_U 3 Phone '545-1 185 <br /> i` TYPE OF WELL/PUMP: NEW WELL },:1VAb6REPLACEMENT n DESTRUCTION D Out of Service Well ❑ <br /> •" <br /> PUMP INSTALLATION D Monitoring Well SYSTEM REPAIR ❑ OTHER d ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE <br /> 4 , FOUNDATION AGRICULTURE'1NEL"L OTHER-WELL-— PITS/-SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well'Casing t1 <br /> (� f1 <br /> Domestic/Private d(Gravel Pack X1 Tracy Type of Casing_ p uC Specifications <br /> I'1 Public El Other n Delta Depth of Grout Seal 100 , Type of Grout R F N T f1 N T Tom_ <br /> 11 Irrigation _ Approx. Depth i I Eastern Surface Seal Installed by H E N N I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth s <br /> Depth Filler Material b Depth <br /> I ' TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIRJADDiTION I ] DESTRUCTION l 1 (No septic system pa(mitte6il public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__W_. Commercial— Other, ? <br /> Number of living units: Number of bedrooms _icy ~rte <br /> Character of soil to a depth of 3'feet:v, s } Water`table depth <br /> SEPTIC TANK' [3Type/Mfg ` Capacity`." No. Compartments <br /> PKG. TREATMENT PLT. ❑ r `' ° Method of Disposal <br /> t Distance to,nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED C_l Distance to nearest: Well Foundation Property Line <br /> SEEPAGE'PITS 11 Depth Size w: Number' <br /> SUMPS I_.I Distance to nearest: Well r Fo darion�` Property Line *y t <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work wiN be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and iegulations of the San Joaquin county i <br /> Home owner or licensed agent's signature certifies the following; "t certify that Ori 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 compejsaflor) 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 persons subje'6t to workman's compensa- <br /> tion <br /> tion Isws of California." <br /> The applicant must call for all required <br /> p_ inspections_. _C_ompleTte dravpb reverse side,,,, �s <br /> Gju, r Date,X <br /> MAY 12 1992 <br /> FOR PARTIME T USE ONLY <br /> 41 to. <br /> Application Accepted by Daie Area <br /> I q 'ai <br /> Pit or Grout Inspection by Data Final I pe on by Date Jr-o`9._3 <br /> Additional Comments: <br /> Applicantr -) Health Services <br /> - Return all copies to: San Joaquin CounPublic 42' �t" �U <br /> Environmental Health Permit/Services 4W j, P-, • <br /> _ (c(,,p,/+ /3-9 , 445 N San Joaquin, P O BOX 2009, Stkn, CA 95201 ^ 4A" <br /> INFO AMOUNT DUE- - y AMOUNT REMITTED y' CASH/.r RECEIVED BY DATE PERMIT N0. <br /> EH:17.24 1PEV.i —S-4.3 <br /> t EH"t1-ZE • � <br />