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RECEIVED APR Z 9 1993 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HX"TH DIVISION <br />445 N SAN JOAQUIN r PHONE (209)468-3420 <br />P O BOX 2008, STOCHTON, CA 95201 <br />(Complete in Triplicate) <br />Application Sa hereby ■ra49 W Sae Joaquin County ter a permit to construct and/or Install the vork her4ln deacrlDed. Thl■ <br />application 1a aide in CaWllanca vtth $an Joaquin Countr Ordlnaeq■ Ro. 549 and 1862 and the Rules and tteaulatSona of Ban <br />Jasquin County lfealth 9or�rico{a. <br />11Put>lio <br />Jab Address'� <br />r r <br />•��-+.����_ __ C,lv ,- ��` '�„�Lot 81me/Ac rea;e sZL,�f;J U +rh 1 <br />Ownyr @Name <br />bU <br />Addrest�����1 i 2�1e�Phone <br />COnlralla <br />'[ <br />f t �'A A3dr! 4 _ 4�� • � � e� _ License He (IaJA� A VJ Phone L t qtil,- <br />TYPE OF WELL/PtjMP <br />NEW WELL (I WELL REPLACEMENT I-1 DESTRUCTION 11 OUt of Service 141j <br />PVIUP INSTALLATION O SYSTEM REPAIR 1) 1%4Arl}A..,AIQTHER k Mott( torIMe vaill (7 <br />DISTANCE TO NEAREST <br />_.r <br />SEPTIC YANK ___ SEWER LINES — _ �_ __ OI$PUSAL FLD PROP LINE <br />' <br />. <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INrENCE0 USt <br />TYPE OF WELL PROBLEM AREA CONSTAUCTION SPECIFICATIONS <br />E I fnduetrral <br />U Open eottOm L) Manteca O+a of Well emcavation - 014 of Well Caarny <br />I I Oorr+asele/Prlvsrs <br />Ll Oravel Pack" 0 Tracy Type of Casing Specifications <br />I I Publie <br />1 1 Olhat 41 Delta 09oth of Grout Seal ---- -- ----- Type of Grout <br />I I Irr�@,Ipr <br />—_ A, piwor Depth I I Eastern Surface seal Installed by <br />P@Oetr Werk Gone Ll <br />We* Destruction 0 <br />Type of Purnp H P S!■t Work <br />t %ss Material a Depth � o e —" <br />WOR Olarnatahit <br />Depth r _ 1111er Material a Depth <br />IY E OF S10fiC WORK <br />NEW INSTALLATION i I AEPAIRIADOITION 1 1 0EsiAucT:ON 1 I tNo sapHc rYtrem r+ d f <br />Inttaltation VA serve Roeldence Corrin steial _ <br />NumNer of 0" urtica Number of bedrooms _. <br />Character of soil to a dooth Of 3 fast. <br />SEPTIC TANK O Type/Mfg <br />PKd TRIAT1AINt f tT Q <br />Dlstence 10 neatest Wall <br />aval,abie within LCN <br />'�test rme Ia p+�bbc sawar in <br />Waller table depth_ <br />Capacity— _ _ No Cornpertrnenta <br />Method of OlVosal <br />Foundat+on ___ Prc+perty Line _ <br />LEACH1140 LINE ^ 0 No A Length of tinea � — _—_- ��-- P/�"�' <br />Total lsngth/srze�_ <br />I tilt <br />iILTiA 8*D n Aistanca to neatest Wail Foundalbn -. PropenY tide <br />Eva <br />Depth 5+ae NVmber <br />3U111P$ Ll Oistafto to nebeat Well _ Foundation _ _ propqrtyti Ulli1 CO <br />DISPOSAL, PONOS UNVIRpL71t f S�Ry rY <br />t hereby certify ilial I have p►spsrod this apVbCat" and that rhe work Will be done in accordance with San Joaquin county Ordi <br />Miss and 109646110rte Of the $an J"quln County <br />Noma owner Or 11Cenaad agent • algnalure cartrfles the fotlowrng I Certify that In the periprmenca of the work for <br />empi0y any R+tapn In Ouch mariner as to become subject to workman wfiuh Ihra perrrpt Is IsauedgI all not <br />a Cortspenratepn larva Of Cadtornra Contractor I hying or sub•contraetin sr nature <br />eitirtilf'" o ca"f �; Cbrllty That in the por}onnanca of the work for which thea permit Is issued I *hall @-ploy peragna rublact !o wo krnan a cvmpansa <br />Tlti@ a fpr r aired <br />g b� }ntpscio+_ drawing On revere ode <br />�Itls <br />r Hata_ ^ i - <br />EOR a! AIRTMENT USE ONLY <br />Appllcatlott Acespted by 'T _ Dattif <br />-_ Area <br />Pk a Grout Inape hon by Data <br />—_, Final Inspection by -�� Osla._ <br />Addltk>Htet Cornmt;nto <br />Applirant - }return all aoptee to, <br />Sart JOaqutn County Publtc IleaIth 94rvicen 29--4VEnvirouanntal Hgatttl Perritt/Services <br />444 N Ssn Joaqutn, P A RON 9000, Stkn, CA 96201 <br />Fel % <br />I%N�Fd yA�Aizolut <br />AMOUNT f1Eto EO CASH �nRei�CEIVEo By' ATE <br />M+ilrt�ty +.nr� Ai >�. <br />tH +r le <br />P[RMJ;N0 <br />