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APPLICATION FOR PERMIT �``' �u �j Q 1/ 7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> SION <br /> PAYMENT P O BOX 20 ENVIRONMENTAL, SKTON, CAI 95201 '��`� �L4 <br /> RECEIVED (209) 468-3447 . <br /> 0 C T 1 1993 PERMIT BRPIR$3 1 YEAR FROM DATE ISSUED <br /> SAN JOAQUIN COUNTY (Complete in Triplicate) <br /> APpllk"WC KA4A*S&khIU55&n Joaquin County for a permit to construct and/or install the work herein described. This <br /> -VX00 #IEWhWEAkT+4WiWW with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.// C�+ <br /> Job Address lS— Alo, Z%11_10Mde 2. City 1T �70� Lot Size/Acreage d-IC <br /> Owner's NamoS+e l P - I Address S2 32 Hclmel Je= jjr GIS Phone 4 7 7 <br /> t-,:M �51=�7/ <br /> Contractors E� �- - a' Address lei../ -7a <br /> -,— License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O V ELL REPLACEMENT O DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER Monitoring Well C1 <br /> S011- j3C,f/ry&; <br /> DISTANCE TO NEAREST: SEPTIC TANK /// <br /> .lL4,_ SEWER LINES ZS ',, DISPOSAL FLD.IV 4 PROP. LINE X51 <br /> F,)UNDATION /Q ' AGRICULTURE WELL 1./� OTHER WELLA&Zd—� PITS/SUMPS AYA <br /> INTENDED USE YYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �+ <br /> Ll Industrial O Open Bottom O Manteca Dia. of Well Excavation C� 4' Dia. of Well Casing At <br /> Domestic/Private. O Gravel Pack O Tracy. Type of Casing A&I C- Specifications <br /> Q Public Kt ther O.Delta Depth of Grout Seal Type of Grout-CM�. <br /> I(rioation '-i�Q Approx. Depth ❑ Eastern Surfico Seal Installed by <br /> Repair Work Done U Type of Pump H.`'. Stats Work Done _ <br /> Wall Destruction O Well Diamotor Sealing Material & Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEVI INSTALLATION D REPAIR/ADDITION L1 DESTRUCTION U INo septic system permitted it public sower is <br /> available within 200 lest.) <br /> Installation will servo: Residenco_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 foot: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Companmants <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ®' <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS O <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 workman's compensation laws of California." Contractor's hiring or subcontracting signature <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 compsnsa- <br /> tlon taws of California." <br /> The applicant mus all 16 all req 'rod inspections. Complete drawing <br /> /oDn reverse side. <br /> Signed Title:W^�StJc ,—^ N)T— '5C z5 /CF 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Data <br /> Additional Commants: / <br /> Applicant - Return all copilfo to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2000, STOCKTON. CA 95201 <br /> 3S 0 l NFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY GATE PERM17'NO. <br /> EN t34-7�1 1ttEV .r,N$1 6 �' oast7�-- <br />