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APPLICATION ~ � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN ,JOAQUIN, PHONE (209)468-3420 <br /> . - <br /> P. O BOX 2009, STOCgTON, 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 1B made in compliance with San Joaquin county Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City jDCkPford_ Lot Size/Acreage <br /> Job Address <br /> T,-,,,�� - 4555 N. Pershing #33-122 St�k o <br /> Owner's Nampkeford Ranches In . Address <br /> lanCkd Dril�_IncAddtesjp 0.13M 64,L_ inden _Ca952Mse No.377923 _Phare — <br /> Contractt r � — <br /> WELL REPLACEMfrNT DESTRUCTION ❑ Out of.Service well 11 <br /> TYPE OF WELL/PUMP: NEW WELL <br /> .PUMP INSTALLATIONS SYSTEM REPAIR ❑ <br /> OTHER`p monitoring Well. <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS � ~' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 3 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'f` Dia. of Well Casing <br /> C) Industrial ❑ Open Bottom ❑ Manteca Die. of Weil.Excavation — — <br /> � Specifications �r' — <br /> Domestic7`Private C3 Gravel Pack :. C] Tracy Type of Casing— A <br /> ,ubbc ���^�.�`_[:7 Other`-""� f7 Delta of Grout <br /> Depth of Grout Seal <br /> r Type <br /> I ! Iriigat;on t���Approx. Depth I I Eastern Surface Seal Installed by <br /> If H p State Work Done _ <br /> Repair Work Done' L3 Type of,Pump Scaling Material Depth, <br /> t` Well Destruction ❑ Weil Diameter - <br /> IT <br /> Depth Filler material i Depth r. <br /> TYPE tF!EPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (Noave septic system permitted if public sewer is <br /> available within 200(eat.) � + <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! Water table depth j <br /> SEPTIC TANK ❑ Type/AAfg Capacity No. Compartments'* �- <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line ' tv- <br /> _ LEACHING LINE ❑ No. & Length of lines <br /> Total length/size y. <br /> FILTER BED ❑ Distance}to nearest: Well Foundation Property tine <br /> SEEPAGE PITS 11 Depth -Size Number <br /> SUMPS L! Distance,to nearest: Well Foundation Property Line <br /> 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 /> 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, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature y <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 California.,, <br /> The applicant u t call t r r uire nspections. Complete drawing on reverse side. <br /> T <br /> Signe itle: & � <br /> R RTMENT USE ONLY + <br /> Application Accepted by <br /> DateAra <br /> t <br /> Date inal Inspection by a72- <br /> Pit or�rgtti Inspection by y . <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 0 Box 2009, Stkn, CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OAT£ Mg <br /> Y W INFO /f r,7yp tiHt�Z1TREY.fi C7� ) )" <br /> s <br /> EN a-za PN <br />