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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201. <br /> (209) 468-3447 <br /> # YEAR VROM DATE T SSUI n <br /> (Complete in Triplicate) <br /> APPlIcation is <br /> San <br /> in <br /> application ie mad* In ccupliance withusonCJooaaquinor a County ordinancermit to nstruct No. 549aando1862stala and thee work Rules andein Regulationsaof Sane <br /> Joaquin County Public Health Services. <br /> Job Address 2Q601 11 - .K,P Wan- 1,a np -.. City—2Qd_ Lot Size/Acreage <br /> Owner's NamaJohn Boethin -Treelanq}dFa-jrmfL323475 Long Valle Rd.Wci%o gnd Hill Ca.. <br /> Contractor Purviance DrilleS644". P. O, Box 64 Lindeig;cense No. 377923 Phone 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER p Monitoring Well t7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES - DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation— 3� <br />' Dia, of Well Casing _ ...' <br /> LJ Domestic/Private 0 Gravel Pack n Tracy Type of Casing <br /> M Public ------ Specifications <br /> 1-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> s §t Irrigation Approx. Depth C] Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump turb H.P. 20 State Work Done_ <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth ` <br /> i <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION Cl Mo se tic <br /> system w� p Y permitted if public sower is <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.) <br /> f Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> i © Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, Ll , <br /> Method of Disposal - <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines <br /> FILTER BEDTonal length/size <br /> n Distance to nearest: Weil Foundation - Property Line <br /> SEEPAGE PITS 11 Depth ,Sire - <br /> Number <br /> LI Distance tance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 /> 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, l 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 permit that in the performance of the work for which this is issued, I shall employ <br /> tlon laws of California." P Y persons subject to workman's compensa <br /> Theplicant mus requi inspections. Complete drawing on reverse side. , <br /> Sig ned Title: CorpSecretes i Date: 2/13/91 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Dots Areay� I <br /> Pit or Grout Inspection by Date <br /> Final Inspection qy Data <br /> Additional Comment <br /> Applicant Re ��/ o �Pto- <br /> -AN IO gy?COUNTY PUBLIC HEALTH <br /> ✓'SERVICESENVIRONMENTAL <br /> — <br /> HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT NO, <br /> EH 13.74 IAIY.I I w er � a �,� �� /�'�jt. 1 A10/� <br /> 1 r <br />