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,1 <br />APPLICATION q3 07�� <br />SAN JOAQUIN COUNTY PUBLICTD� V %�� O� <br />1 <br />ENVIRONMENTAL HEALTHS 445 N SAN JOAQUIN, PHONE 3420 <br />J701P O BO% 2009, STOCKTON _ <br />(Complete in Tripli i��# /V 45? <br />Applicstlon is hereby made to San Joaquin County for a permit to construct !! a !ti7r+leeMap <br />application is made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the ee g�Ietrlew <br />Joaquin County Public Health Services. <br />Job Address _ 865 E RothRd Citv'Fr.- nrh C..amTLot Site/Acresxe 7 S <br />S <br />OwrW*&Nam. acifiC Precast Address 3508 nPpot Rri Hayward Phone <br />Comlactor C I a r k <br />1 1 Address License Mo. 3_:�7 75 C�Phone <br />TYPE OF WELL/PUMP <br />NEW WELix6DXX WELL REPLACEMENT Fl DESTRUCTION Ll Out of Service Well ❑ <br />DATE PERMIT'NO. <br />PUMP INSTALLATION C SYSTEM REPAIR C OTHER O Monitoring Well v <br />DISTANCE TO NEAREST: SEPTIC TANK{. 39 + SEWER LINES DISPOSAL FLD_ PROP. LINE �§! <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Ll Industrial <br />C Open Bottom ❑ Manteca Dia. of Well Excavation 16 tl Dia. of Well Casing 1+ <br />1 Domestic/ Private <br />?L�7 Gravel Pack• ❑ Tracy Type of Casing_ E. e 1 Specifications , <br />f') Public <br />(-1 Other f-1 Der.a Depth of Grout Seal I owe Type of Grout 9 k a 4x14 <br />I i Irrivalion <br />Approx. Depth I I Eastern Surface Soul Insla-Aad by <br />Repair Work Done U <br />Type of Pump S l i h H .P. S State Work Done = n e f, <br />Well Destruction n <br />Wall Diameter Sealing Material 4 Depth I <br />Depth Filler Material A Depth <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION I I REPAMIAOOiTION I I DESTRUCTION I I (No feplic system permitted it public sewer is <br />available within 200 fset.) <br />Installation will serve: <br />Residence ^ Commerclet _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of ION to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: Weil _ _ Foundation Property Line <br />LEACHING LINE <br />O No. & Length of lines _ _ Total length/size <br />FILTER BED <br />❑ Distance to nearest Well Foundation Property Line <br />SEEPAGE PITS <br />11 Depth Size , Number <br />SUMPS <br />1-1 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />0 <br />^- -•-r--••••r •••--v Y�ya•w •� •+pp—ptrvn ■rtu inoi urs YYonl w111 De cone in accordance with San Jnaquin coimly ordinances, stale laws• and <br />rules and regulations of the San Joaquin Comty <br />Home owner or licensed agent'& .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 workmen's compensation laws of Cslil la." Contractor's hiring or subcontracting signature <br />certifies the following. "I certify thst in the performance of the work for which this permit Is issued, I shell employ persons subject to workman's compensa- <br />tion laws of California." <br />The apDliun!OAF/ - fid: r1quk j4;Zti4js CgIll(plete drawing on reverse side. <br />Signed x ! !"�/" L�+-Y(J�•/LJ Title: VP C l a k We 11 ' T ns Date-- 1 <br />Application Accep!ed by <br />Pit or Grout IfYpection by <br />Additional Comments: <br />Apyl gcrc int - Re-t-urrn all /c <br />\�Z FEE <br />EN 11-74 IREV, r iA s <br />FH 14.78 <br />FOR DEPARTMENT USE ONLY <br />Date .10 !02 7 Final <br />to. <br />Date <br />San Joaquin County Public stealth servicesC� <br />Environtaental Health Permit/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />INFO <br />AMOUNTDVE <br />AMOUNT REMITTED <br />ASM <br />RECEIVED BY <br />DATE PERMIT'NO. <br />wN, <br />r <br />U. <br />