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1 APPL•ICAT7ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAyp', <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED �' ;rs � 9 <br /> 993 <br /> " (Complete in Triplicate) d ­qCOUVy <br /> .v.�(ti , daµ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work hereinser-ibd�. �� <br /> i application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of S�op'r <br /> Joaquin County Public Health Services. <br /> Job Addresslmd City Lot Size/Acreage 14-7 _ <br /> . I <br /> Owner's Name CheyrOri U.S.At Products Address 1 a RaMM CA Phone f 51�) <br /> Contractor West Ha.Zmat Drilling Ad8ress8261 Etlte :prise Dr.Ne�icense No. 057554979_Phone 494-8111 <br /> TYPE OF WELL/PUMP: NEW WELL IXX WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 50' PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl lndustrial O Open Bottom Cl Manteca Dia. of Well Excavation "1 f0 r_ <br /> Dia. of Well Casing rr <br /> Cl Domestic/Private XX Gravel Pack 0 Tracy Type of Casing_ PVC Specifications <br /> I'I Public Cl Other n Delta Depth of Grout Seal 5 r Type of Grout.--CE'-MMt — <br /> I I lrrigation Approx.. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. 1 State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth' <br /> k . Filler Material & Depth <br /> � Depth 30 r _ <br /> s TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION E I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> ' Installation will serve: Residence? Commercial — Other t. <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. 0 1Method of Disposal D <br /> Distance to nearest: `Well Foundation Property Line <br /> i <br /> 4 LEACHING LINE _, ❑ No. & Length of lines f Total length/size <br /> r <br /> FILTER BED. r [.l Distance to nearest: Wail Foundation Progeny line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ J <br /> I hereby cenify 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 compensa- <br /> tion laws of California." 71 <br /> The applicant mus f I re edt in ons. Complete drawing on reverse side. <br /> r 2 <br /> Signed Title- Dale: <br /> Date: Y <br /> fi FO DEPARTMENT USE ONLY <br /> �y 13 , <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by. <br /> �'Yf• 'i�� Date -1 13 ' Final Inspection by-7_7y7. —_ Date <br /> Additions!Comments: 3 "� W <br /> Applicant —Return all copies San Joaquin County Public Health Yervices Q D <br /> Environmental Health Permit/Services I � <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �- <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> INFO ��`/�� �{� •/�� �} -�1,nir�' �] G �`� <br /> . £H 13-24 ip£v,i i n 51 <br /> EH 14.20 <br />