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' APPLICATION FOR PERdiT <br /> I - <br /> ti SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERXIT E%PIRFsS 1 YEAR ?9Q1! DATE ISSUER p SqN FB t/� <br /> (Complete in Triplicate) �NQ�/e o �9�Q <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the / `ft�efd. This <br /> applicatioa•,Sa;s+ade iri:i„nomplfance.;xi.th•San.Jonquiri;county Ordinance No. 549 and 1662 and the Rules�¢� dyt7�� of San <br /> i �/ r` Y <br /> Jo�qufa Cotuity Public health 8er'vicre. 14 <br /> * F 2 � - City Lot Sire/Acreage rye/CC`S <br /> Job-Addresi <br /> J6N.� $o�GEs E'35,» fol(yp N <br /> Owner's Name John C l ever.l Address P.O. BOX 691 , Tracy Phone 835-9090 <br /> r x . <br /> Contractor Hann!nnc-Rrnc,_ _Address License No. _ 29081 Phone - <br /> 1185 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Uout of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ : Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> tt ..FOUNDATION_ AGRICULTURE-WELL —_OTHER.WELL PITS/SUMPS.___._ - — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial Cl Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> F ❑ Public Cf Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> I 0 Irrigation Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State WorimDone_ <br /> Well Destruction Well Diameter 6 a Sealing Material i Depth _ ] <br /> Depth IUgkggM# .35” Filler Material Z Depth B e & Ug <br /> TYPE OF SEPTIC WORK;" NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted i publi sewer is <br /> I <br /> available within 206 feet.) } <br /> installation will seri e:~14Residence Commercial— Other ry 9 <br /> { Number of living units: Number of bedrooms <br /> f Gharacterof,soil to ea depth of 3 feel: '•" I Water:iable depth <br /> SEPTIC TANK: Or Type/Mig Capacity• No. Compart6nts <br /> PKG. TREATMENT PLT,❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j <br /> t <br /> LEACHING LINE L1 No. 8 Length of lines _ Total length/size <br /> FILTER BED ❑ DistancetoHearses: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth 'Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property,Line _ <br /> f. <br /> DiSPO$AL PONDS 0'� <br /> I hereby certify that 1 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 /> I Nome 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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature ' <br /> G certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of Cahfornla."+ <br /> i The applicant must call for all required inspections. Complete drat ing o .fever de. <br /> SignedDate: 2-15-91 <br /> r <br /> FOR DE RTMENT USE ONLY <br /> Application Accepted by DateArea <br /> Pit or Grout inspection by Date final Inspection by "x Data / <br /> Additional Comments: — <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH *RECEIVED BY DATE r /yPERMI7'N0, 7 �( <br /> . EM 19.74(REV, i n 0) AbOMt �`f� <br /> EH,4•x c r <br />