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.�� APPLICATION — <br /> SAN AQUIN COUNTY PUBLIC HEALTH RV I C �, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 SEP 6 1991 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ENV!RONNitNTAL HEALTH <br /> PERbdIT EXPIRES 1 YEAR FROM DATE ISSUED PER N1! i 1 SERVICES <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 /6 777 hYowc,g.vn �aw_/. CityLot Size/Acreage !/NX. <br /> Owner's Name f. SrMp co T r_'o. Address �� 7 77 /�ozut,9..t? - Phone S,' <br /> i Rt.4 TG,r -�'�"�• e17v! L�. /SGA•«..+c.c .C.,u �io,7 �`9 9�3 dr J a!-9 p•t-amu�o <br /> Contractor 4,.44�7d C lJ�✓cto "T Address 12oz !C<<a-7ycany- zvuoa&-4 .o License No. XB3 3 a Phone 224- 6 4.0 48ci 9 <br /> TYPE OF WELL/PUMP: NEW WELLS of WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 SPECIFICATIONS11 <br /> Industria QFhth -770A'❑ Open Bottom MantecYAA?04g0ia. of Well Excavation Za Dia. of Well Casing <br /> F.) Domestic/Private ❑ Gravel Pack L1Tracy Type of Casing_ 47-4-6,L Specifications <br /> I'1 Public >COther (l Delta Depth of Grout Seal /Ol / Type of Grout 0.,/ <br /> I I Irrigation 07L-Approx. Depth I I Eastern Surface Seul Installed by 41.0 T­eof dL✓.c <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material Depth <br /> Depth Filler Material L Depth <br /> 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 feet.) <br /> Installation will serve: Residence_ Commercial_ O:her <br /> Number of living units: Number of bedrooms D <br /> Character of soil to a depth of 3 feet: CN0 <br /> de <br /> SEPTIC TANK ❑ Type/Mfg Capacity p nt <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Fcundatton Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I 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 persons subject to workman's c6mpensa. <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing onreverse side. f <br /> Signed X /f Title: /,'ey,7Y L� /19/1Z'�/}Z Gc. Date: <br /> FO PA T T USE ONLY ,7/ <br /> Application Accepted by Date ` J Area ` �� <br /> Pit or Grout Inspection by C Date ( Final Inspection by G Date <br /> ' <br /> Additional Comments: a�4� l �� <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 �� 5 <br /> CK S <br /> INFO AMOUNT DFEE UEl AMOUNT REMITTED ��CQAS�H RECEEIIVEEDD�/BY /yy DAA'TEE g PERMIT(/ANO. <br /> '_r <br />