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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �r ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE(209)469-3420 <br /> P O BOX 388,STOCKTON, CA 95202-0388 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110 3 and Section 9-1115 3 and the Rules and Regulations of San Joaquin County Public Health Services <br /> Job Address __375 Waist HasteltM Road TT C„y Stockton Lot Size/Acreage <br /> Owners Name liar la Lumb= Address Sam an above _ Phone <br /> Contractor Gust Sierra Exfllalrati4miess 7460 Redwood alvd. , N�aL�nse No 610487 Phone 4151298-1186 <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT I-1 DESTRUCTION 1=1 Out of Service Yell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1h Monitoring Well ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP°LINE��9 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Drs of Weil Excavation Dta of Well Casing <br /> F1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specthcatrons <br /> f 1 Public 1-1 Other P Delta Depth of Grout Seal Type of Grout <br /> i kr,gatwn —Approx Depth I I Eastern Surface Seal Installed bV <br /> Repair Work Done U Type of Pump H P State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth_ filler Material & Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public serer a <br /> available within 200 fest I <br /> Installation will serve Residence— Commercial_ Other <br /> Number of living units Number of bedrooms <br /> Character of sod to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ i-Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No 8 Length of Innes Total length/size <br /> FILTER BEI] ❑ Distance to nearest Wall Foundstwn Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances stag tame, and <br /> rules and regulations of the San Joaquin Couatr <br /> Home owner or licensed agent's signature certifies the following I carnfy that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman a compensation laws of Caleforrua Contractor's hiring or suacontrectrng egnsture <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 a compensa <br /> tion laws of California-- <br /> The <br /> The applrcmust cell for all required inspections Complete drawing on reverse side *16 See attached Site Map” <br /> Signed nt 1 t fi I y`_ fe, PreeJaent .. Date 6/2/94 <br /> 74 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Ansa 'IU' <br /> Pit or Grout Inspactton by Date Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return all copiestq San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin,P O Box 388,Stockton,CA 95201-0388 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED Ely DATE PERMIT NO <br /> fM �IrtiV r,�si UD az 't,1�44 <br />