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� . APPLICATION <br /> SAN JOYUIN COUNTY PUBLIC HEALTH S1CES <br /> _ ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209')468ih3420 <br /> P 0 BOX 2009, STOCKTON, CA' 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 add 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 4{ <br /> Job Address 1320 W. Weber Ave. city ,Stockton_ Lot Size/Acreage - <br /> �I <br /> Owner's Name Union Ice Coil an Address 1320 W. Weber Ave. Phone 20 48--1231 <br /> Contractor Osterberg & Stewart Address 2741 Road, Modesto LicensejNo. 446670 Phone (209)537-5767 <br /> I TYPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER M Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL i <br /> ; FLD. PROP. LINE <br /> See p FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S Soil Borings <br /> M Industrial ❑ Open Bottom ❑ Manteca Oia. ofWvIrExcavaficn4M Dia. of Well Casing <br /> rl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �} It Specifications <br /> I'i Public 11 Other n Delta Depth of Grout Seat Max., 117'- __ _ Type of Grout Neat cement l t <br /> • it <br /> I t Irrigation Approx. Depth l I Eastern Surface Seul installed by <br /> Repair Work Done U Type of Pump H.P. State Wark Done _. <br /> Wets Destruction ❑ Well Diameter Sealing Material 4 Depth I� <br /> Depth Filler Material E Depth !� <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I DESTRUCTIOf! t I IN6 septic system permitted it public sewer is <br /> available within 200 feet.) <br /> I <br />�f. Installation will serve: Residence— Commercial— Other I <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK C1Type/Mfg Capacity I No <br /> PKG. TREATMENT PLT.❑ i} <br /> Distance to nearest: Well Foundation IPropertyiFf_ -I-VED , <br /> LEACHING LINE El No. A Length of lines Total length/size Lt�I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prlp t QOi <br /> n'U l-1 ICES <br /> LiNiV <br /> SEEPAGE PETS 11 Depth Size Number 1� <br /> SUMPS LI Distance to neatest: Welt Foundation Priokpeny Line <br /> DISPOSAL PONDS ❑ Ii <br /> I hereby certify that I have prepared this application ano that the work will be done in accordance with[San Joaquin county ordinances, state taws, 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 taws of California?'Contractors hiring or sub-contracting signature <br /> k certifies the farrowing:"I certify that in the performance of the work for which this permit is issutid,I shall employ persons subject to workman's compensa- <br /> lion laws of California." :k l <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> �l <br /> Signed X Title: Data: <br /> FO EPAR <br /> TMENT USE ONLY tr0p <br /> V <br /> Application Accepted by Data 1 Area r 1 <br /> i�. <br /> Pit or Grout Inspection by Date Final Inspecticn`by Date i <br /> Additional Comments: <br /> ii <br /> Applicant - Return all copies to: San Joaquin County Public Health Service's 4 <br /> Environmental Health Permit/Services it <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> k y <br /> iNFO AIMOUNT DUE AMOUNT REMITTED CASFr RECEIVED 8Y i� DATE PERMIT NO. r` <br /> 3 •j2 ENiY2,IJ1EV.,,rs, , oo . C t�3 l3. ga- 03 r <br />