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-^APPLICATION I✓JR PERMIT <br /> SAN JOAQWT COUNTY PUBLIC"HEALTH SERV S I 1 , <br /> ENVIRONMENTAL HEALTH DIVISION ' ��u <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) j468-3447 SE'P1 S 1995 <br /> PERMIT RMI EXPIRES 1 YEAR PROM DATE ISSUED <br /> - a. <br /> _ <br /> (Complete In Triplicate) ENVIRONME. ,PERMIT/SEAICESt h <br /> 7plicatlon Is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> pplicatlon Is made In compliance vlth San Joaquin County Ordinance He. 549 and 1862 and the Rules and Regulations of San <br /> xq,ufn County Public Health Services. y <br /> ib Address /�6/�(�7d��,ef074 <br /> Address /%T'"" t-'31`7, 2a <br /> ",'�-[/D Lot Size/Acreage p"'IZryO <br /> o, 3ax. / 2Q l/1 r ee? g-S2? Phone <br /> I �Rec°e N+ms 31/ 7v ZI ' <br /> *nit8f.lor <br /> Address "r'N/�� u�OYi� License No. /LQ___-^�"�Phonee �l -02// <br /> A NF WELD L/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION O Out of Service Well <br /> PUMP INSTALLATION"O SYSTEM REPAIR D <br /> Monitoring Well <br /> ^TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> ,. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ¢ n <br /> Industrial O Open Bottom 6LManteca Du. of Well Excavation �0 / Dia. of Well Casing v <br /> fa0euedic/Privets 9f6 <br /> ravel Pack O Tracy Type of Casing pVC. Specifications <br /> Depth of Grout Seal Typo of Grout nl <br /> ?ttblie I.1 Other O Deltaep <br /> luktViion —Approx. Depth ❑ Eastern Surface Seal installed by r <br /> r exi Work Dona U TYPO of Pump _„_ rH.P. State Work Done <br /> mH GQstruetlon O Well Diameter Sealing Material i Depth <br /> Depth Piller Material L Depth <br /> f^pE OF SEPTIC WORK: NEW'INSTALLATION O REPAIR/ADDITION Cl DESTRUCTION U availabbrw shin system emitted if public sower is <br /> ((�I <br /> t1glistion will serve: Residence _ mmercid_ Other W <br /> id�nmbar of living units: _ Nu er of bedrooms` I <br /> Character of sail to a depth of asc Water table depth <br /> £DTIC TANK- O ITYPGIMIQ Capacity No. Compartments <br /> TREATMENT,PLT Method of Disposal <br /> Dista nce to serest: Well Foundation Property Line <br /> <'GHING LINE CI . b Length of litles" Total length/size <br /> ,TER BED Distance to rest: Well Foundation Property Line If <br /> tFVAGE PITS - 11 De Size Number I` <br /> imps Ll Istance-to neatest: Well Foundation Property Line <br /> [POISAL PONDS I <br /> --orsby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, 31310 IS an <br /> yes end regulations of the San Joaquin County <br /> +s owner or licensed agent's signeturs certifies the following: "I cantly that In the performance of the work for which this permit is issued, 1 shall not <br /> ,::tgV any person in such manner as to become subject to workman's compensation laws of California." Convector's hiring at sub-contracting signature <br /> -Jfks the fallowing: "I cattily that in the performance of the work for which this permit Is issued, I shall employ persons subject to workman's tarnpana- <br /> -a Pdvw of C am a." _ <br /> .,a eppfka test call 1 requir In no. Complete drawing on re se'side:• <br /> ;seed • Tltb: — Date: J / <br /> (./`'-/ OR DEPARTMENT USE ONLY <br /> ;aftatlon.Accepted by .�� Data L �0 Area 6 / <br /> et Grout Inspection by Dare Find Inspection by Date <br /> .adldond Comments: <br /> Z 3 - <br /> ,plicant - Rat= all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 95201 <br /> FEECK I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PfRMIT'NO. <br /> Y Ie EV.r/eel <br /> A j,l IP -za �s oo13Y5 4 <br />