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APPLICATION FOR PERMIT , <br /> SAN OAQUIN COUNTY PUBLIC TH` VICES <br /> ENVIRONMENTAL HEALTH DI ISI <br /> 445 N SAN JOAQUIN, PHONE (20 <br /> P O BOX 2009, STOCKTON, C 9001 <br /> PERMIT EXPIRES 1 YEAR FROM D TE� <br /> (Complete in Triplica eINV � <br /> an <br /> Application in hereby ds to San Joaquin County for a permit to construct an 1��!! ere n described. This <br /> application in mde In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ti4'I 1 L <br /> Job Address 2905 W. B� ✓1,l Lw10 14 Dl>r I ve A City S+Wisackr6A Lot`Size/Acreage <br /> Owner's Name / 4levron GS/4 P✓WQ/��Address f'_ l�DC$/11/�� �I�Li� rXl� hone 0 FYZ" <br /> S 3$3 f 5, i lc 4' -707-1 -7VSContractor s License fesAN�, <br /> Phone <br /> TYPE OF WELL/PUMP: NEW M <br /> WELL Q WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 7X1000�� SEWER LINES ���C�� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 7 (Qi�Jz AGRICULTURE WELLyc - OTHER WELL 21-60PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f! <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �Vc- Specifications <br /> I'1 Public (Other (-1 Delta Depth of Grout Seal �d/ Type of Grout k lea <br /> I I Irrigation 3��Approx. Depth I I Eastern Surface Seal Installed by 9Vi1hg&4 Di111104 <br /> Repair Work Done U Typo of Pump H.P. — Stat Work Doe _ <br /> Wall Destruction O Well Diameter 2 r� Sealing thterial 6 Depth /lrWemee4lAeAlyn/ <br /> .© Netirorrt. Depth 3S/ Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will sorvo: Residenco_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Charcetor of coif to a d^pth of 3 feet: Water tablo depth <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Lino (0 <br /> LEACHING LINE D No. & Length of lines Total length/size V ' <br /> FILTE e l oundatron Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS LI Dis ,rust: Wall Foundation Property Lino <br /> Elm 4 NDS ❑ <br /> 1 hereby certify that 1 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 /> Homo ownor or ficcneod egont's signature cortifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such mannor as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> eortifias tho fotSowing:"I certify that in the performenco of the work for which this permit is issued, I shall employ persons subject to workmen's componsa- <br /> tion laws of California." <br /> The applicant ell for ell roquoo inspaetions. Complete drawing on reverse side. <br /> Signed Title: <`''ed e fo ,S/ Date: 7 _ Q <br /> Application Accepted by Data Asea <br /> FOR DEPARTMENT USE ONLY �1 z� � � \ <br /> `' '� J <br /> Pit or Grout Inspoction by Date Final Inspection bye--�� <br /> Additional Comments: WeW <br /> - - <br /> Applicant - Return all copies to: San Joaquin County lublic Health Services <br /> Environmental Health Permit/Services RECEIVED i iAY 7 -1993 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> {NFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED 6Y DATE PERMIT'NO. <br /> . EH1114.27 24(REV,1/"5) �- 14639 <br /> EH cb/6,rj <br />