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5 l <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> `445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXP 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> and/or install th <br /> Application is hereby made to San'Joaquin County for a permit to construct e work herein described. This. <br /> application is made in campliance.vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ser(ices. HARLAN RD.LATHROP Lot Size/Acreage <br /> 85 E. LOUISE AVE.-BETWEEN HWY 5 & City <br /> Job Address 983-9140 <br /> Owner's Name <br /> ARCO FACILITYI16080 Address 85 EAST.:LOUISE .AVE.. LATHROP Phone <br /> KENNINGS BROS. Address <br /> 3525 PELANDALE . MODESTO License No. <br /> 2�a� 813 Phone 545-1 185. . <br /> Contractor ���-- WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ <br /> NEW WELL ❑ OTHER ❑ Monitoring Well C1 <br /> TYPE OF WELLlPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK. ��-- OTHER WELL PITS/SUMPS <br /> FOUNDATION �---- AGRICULTURE WELL _ <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. at Well Casing <br /> ❑ Open Bottom ❑ Manteca Die. of Well Excavation <br /> L7 Industrial <br /> Domestic/ ❑ Gravel Pack Type of Casing- Specifications <br /> C7 Tracy Type of Grout <br /> [1 Cl Delta urface Depth of Grout Seal {� <br /> i'i Public 1-1 Other Seal installed by <br /> I i Irrigation Approx, Depth I I Eastern S <br /> H.P. Stats Work Done n tQp 100' <br /> Repair Work Done LZ Type of Pump - <br /> n Sealing Material 6 Depth Perms � <br /> Well Destruction Well Diameter ------ <br /> -- ' <br /> t Filler Material *`.Dep <br /> 3'. r Depth 's —.-`t: <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I IDESTRUCTION I i 3Naikabltic 5 sin m rmiitted'il public sewer is <br /> Instillation will ser've:" Residence i Commercial— Other <br /> Number of bedrooms t,�:: 4'�J <br /> Number of living units: ;. ;�, )', Water table depth <br /> Character of soil"to 4 depffi`of 3 feet: °Capacity -- No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , Foundation Property Line_�--- <br /> Distance a to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. 8.1LengtFi of lines Foundation Property Line <br /> FILTER BED 11 Distance to nearest: Well <br /> SEEPAGE PITS I I Depth <br /> Size Number <br /> �.�---- Property Lina <br /> SUMPS LI DistancFoundation e to nearest: Well r <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joarjuin county ordinances, stale laws, and <br /> rules and regulations of the San Joaquin County �rk for he fg• <br /> Home owner or lice nsed agent's aigas to becomfe subjecties t lto workmanIsrtcompensation lthat in the awsofCaliforrr iahe Contractor'shir ng or sub-contracting lsignlatuore <br /> employ any person in such manner <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compens ._ <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing o reverse sid 7M29-92 <br /> Date: <br /> Signed <br /> Rennin S Bros. Title: <br /> FOR EP N SE ONLY fj <br /> I` ate z- Area '210 X <br /> 4 Application Accepted by l <br /> � pate _ <br /> ate Final Inspection by <br /> Pit or Grout inspection by <br /> Additional Comments. <br /> t <br /> 1, Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> . x}45 N San Joaquin, p O Box 2008, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> (225;4/ RECEIVED BY AT PERMITNO. <br /> INFO <br /> . EH 17.24 llIEV.i r n sl WO (� <br /> E. EH 14.25 { <br />