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i APPLICATION <br /> 1 , SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> DIVIS <br /> 445 N SVANRO OgQ IN, PTAL HONE (2 9)46 <br /> P O BOX 2009, STOCKTON, CA 95 Qilt <br /> 1N11! <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> 3 (Complete in Triplicate) <br /> i � ��� <br />' Application is hereby, made to Sew Joaquin County for a permit to construct end/or i atA�nlStlr work here In described This <br /> application is made in compliance with San Joaquin County Ordinance No 549 and l$ _and the as and a ons <br /> Joaquin County Public Health Services. <br /> t � LQ� <br /> w74 ' OCity AddresskCk Lot Size/Acreage <br /> . C12�a Y s�.taxs+� <br /> r Owner s Name d Ili�' Address S is Phone-$d0-?q2-10E <br /> I <br /> Contractor y �'�k r Address 15,°�- LtceIC,GRI, Photic 6` 3 t ^71`.f <br />' z TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT C-1 DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> -FOUNDATION AGRICULTURE WELL OTHER'WELL: " PSTS/SUMPS <br /> s _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />' Cl Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation in" Dia of Well Casing <br /> ppt .ec pomestiel VL Gravel Pack ❑Tracy Type of Casings 40 Hr. a=Cr_,;Lc'gp41c,j1cations5eL4 W3 PVCG <br /> I 1 Public *°� n Other n Delta Depth of Grout Sea] I Type of Grout � S"Ln <br /> I I Irrigation BsApprox Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H P State Work Done ° <br />' r <br /> Sealing Material & Depth- <br /> Well Destruction ❑ Wel! Diameter - '- <br /> 1 Depth Filler Material d Depth C <br /> TYPE OF SEPTIC WORK NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted If public sewer is <br /> r available within 200 feet i <br /> Instaflatlon will serve Residence— Commercial_ Other <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Oisposal <br /> Distance to nearest Well Foundation Property Line VJ <br /> LEACHING LINE 0 No b Length of Miss Total length/size MAY 7 K 1994 <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line SAN fnAQUJAJ COUNTY <br /> _ PUBLIC HEAP TI [•rr•... <br /> - --- RONMENTALHEALTHDIVISiO <br /> I <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest Welt Foundation Property Line <br /> DISPOSAL PONDS C7 <br />' i hereby certify that I have prepared this application and that the work will be dome 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 "t 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 r <br /> certthes 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 compensa <br /> tion laws of California ' <br /> The applicant must call fa�9lE required inspections Complete drawingon�re�er *�side <br /> Signed I� i-'�^ �-' Title r ' ` _ �" 1V 0 t 1f r T Date s / <br /> FOR DEPARTMENT USE ONLY <br /> g <br /> Application Accepted by Date <br /> Atea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> • Additional Comments , lt <br /> `S <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services5o <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 j <br /> FEE AMOUNT DUE AMOUNT REM17TER CK CASH RECEIVED BY DATE PERMIT NO <br /> I O <br /> EIS 132,IREV „KSI V f ,Ls Atz L5,2S oO,z z <br /> EH t4 2e <br />