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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> application is made in eoatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br />' Job Address <br /> 633 N. Holden City T•indpn Lot Size/Acreage <br /> Owner's Name <br /> Albert E Mapes, Jr�Address Phone <br /> rviance Drilles 1ficess R. O ox 6. -F No. Phone - <br /> CoMrac$dcl t of Service Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL W WELL REPLACEMENT Cl DESTRUCT)0 Ll <br /> Ij PUMP INSTALLATION IN SYSTEM REPAIR ❑ <br /> OTHER 13Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Industrial Open Bottom ❑ Manteca Dia. of Well Excavation"���- <br /> ['11 Domestic/Private <br /> Pack L7 Tracy Type of Casing Specifications <br /> ther n Delta Depth of Grout Se Type of Grout <br /> VI Public � - - <br /> �[}ElrriUation 6QbrAp ox. Depth - I I Eastern Surface Seai installs <br /> Repair Work Done ❑ f Pump� H.P. t� — State Work Done_ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION I I REPAIR/ADDITION I V DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> r Water table depth <br /> SEPTIC TANK. © 7ype/fvlfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distinca to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ Nd. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation _Prgperty Line <br /> SEEPAGE PITS I 1, Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> I' DISPOSAL PONDS ❑ <br /> I 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 /> Hama 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 /> emptoy 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 certif 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 ifomia. <br /> 1 The plic tete drawing on reverse side. <br /> Sign <br /> Title: Corp. Secretary Date: 3/12/92 <br /> t 4FOR DEPARTMENT USE ONLY R <br /> Application Accepted by t'` - Date 3 "� Area - — <br /> P? rout pection by Date Final Inspection by Date <br /> Additional Comments: <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 <br /> IFEE AMOUNT DUE AM NT REMITTED CKS CASH RECEIVED By DATE PERMIT*NO. <br /> EH13-24(REV.i/psi 13`� rC ' rZ , a^� <br /> EH 14.20 L: <br /> .. - <br /> i <br />