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APPLICATION FOR PERMIT <br />SAN JOAQUiN COUNTY PUBLIC HEALTH SERV1_,i <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />(209) 468-3447 S E :' 1 5 1995 <br />ENVIPONMP ITAL. HE AL:7:--PERNMT/S1:2V1CFc <br />'lira tion is hereby made .to San Joaquin County for a permit to construct and/or install the work herein described. This <br />)10,u &Lion is made in ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Address 456/-5--- 7 2 C.:74-,,# e 7' g.,4-2y,f4,-Ar At7),Z Lot Size/Acreage --/a40 >C141f, <br />,A.t,p1 n County Public Health Services. <br />of75 ?-13 f (f <br />qnce. 6 Name 1122a_C /9 /avy..47) Address Po .3a)( 97 2a #(,- of _ 9-6-luo Phone <br />1/'( Addres s 17 3° ofT2thoct , 7 7, 4 P' 1 M k- License No.6 73504 Phion-e1C19°-4)1 -02/1 <br />NEW WELL 0 WELL REPLACEMENT DESTRUCTION 0 Out of Service Well 0 <br />M <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 <br />0 <br /> <br />Mon itoring Well It <br /> 411,' <br />STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE — <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br />PERMI3 EXPIRES 1 YEAR PROM DATE ISSUED <br />(Complete in Triplicate) <br />.OF WELL/PUMP: <br />INTENDED USE <br />Industriel <br />Oomestic/Private <br />PibIic <br />It rigation <br />oair Work Done 0 <br />a9 Destruction 0 <br />4 <br />Dia. of Well Casing 2 4" <br />Specifications Pv <br />Type <br />- <br />Type of Grout ti 'd <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />0 Open Bottom 5ii Manteca Dia. of Well Excavation /0 i' <br />Pkravel Pack 0 Tracy Type of Casing <br />0 Other 0 Delta Depth of Grout Seal <br />_ Approx. Depth 0 Eastern Surfice Saul Installed by <br />Type of Pump H.P. State Work Done <br />Well Diameter <br />Depth <br />2-4 Sealing Material & Depth <br />Tiller Material II Depth <br />'. OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ACIOITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br />available within 200 feet.) <br />tallation will serve: Residence mmercial Other <br />Iber of living units. — Nu er of bedrooms <br />.eracter of soil to a depth of eet• <br />v TANK 0 ype/Mfg <br />TREATMENT- ?LT <br />Distance to serest: <br /> Well <br />Capacity <br />Water table depth <br />No. Compartments <br />Method of Disposal <br />Foundation Property Line <br />IING LINE <br />. ER BED <br />. & Length of lines Total length/size <br />Foundation Property Line Distance2e6Ct: Well <br />iGE PITS I I De Size Number <br />'S LI.,stance to nearest: Well Foundation Property Line <br />iereby 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 />iee •nd regulations of the San Joaquin County <br />n•tt; 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 />vt.At-lif any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br />les 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 />awe of C fornla." <br />sapplica ust call I r requir <br />X <br />FOR DEPARTMENT USE ONLY <br />Area <br />, • Grout Inspection by Data Final Inspection by <br />tional Comments: *el); 3) el/ Cal/ t 13—/ ( <br /> Date <br />to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br />SF r/SAL PONDS <br />ns. Complete drawing on re se'side. • <br />Date - 9--Ar-fr <br />>plication Accepted by Data <br />1.1camt - Return 1.11 copies <br />t. tins <br />FEE <br />INFO <br />AMOUNT DUE <br />CX r <br />CASH <br />9-7 /4U- iz9007.315 <br />AMOUNT REMITTED RECEIVED BY <br /> DATE <br /> PERMIT NO.