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APPLICATION { ,1�\) Y�� <br /> JAN 2 6 1qg� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C Q QD�OD <br /> ENVIRONMENTAL HEALTH DIVISION �lL� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 \` / <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O IV # <br /> (Complete in Triplicate) # <br /> f <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> pplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> oaquin County Public Health Services. s <br /> Job Address 30350 South Tracy Blvd . , City Tracy Lot Size/Acreage <br /> 94566 <br /> caner's Name RMC Lonestar Address P .O Box 5252 Pleasanton Phone 51 0-426-2279 <br /> Commerce City 303- <br /> ontractor Becker Drills Address POB 567, CO 80037 License No.C'–")7#>t441 Phone – <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SQil OTHER)a Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES N/A DISPOSAL FLD. N/A PROP. LINE 1000 r <br /> FOUNDATION __N,_/_A AGRICULTURE WELL N A OTHER or l ng ITS/SUMPS NLS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ii Industrial O Open Bottom ❑ Manteca Dia. ofXWIKExcavauon 811 <br /> Dia. of Well Casing N/A <br /> I Domestic/Private ❑ Gravel Pack r Tracy Type of Casing_ N/A Specifications N/A <br /> —1 Public IXDiherBorings n Delta Depth of Grout Seal Full Depth Type of GroutNeat Cement <br /> (((W <br /> I I Irnpauon 10 Q Approx. Depth I I Eastern Surface Seal Installed by <br /> epair Work Done U Type of Pump H.P. __ State Work Done _ <br /> Jell Destruction ❑ Well Diameter Sealing Material i Depth yy���� <br /> Depth Filler Material i Depth PAYMENT V 1 <br /> OF SEPTIC WORK. NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic SlAtM&M rMsublic sewer is <br /> available wit i feet.) <br /> Installation will serve nce _ Commercial _ Other �." <br /> Number of living units: r of bedrooms <br /> Character of Boll to a depth of 3 feet: W 1.4 Cj;�rtr'CcJ n <br /> _EPTIC TANK O Type/Mf Capa � �� d1 l� <br /> g �iR���r'Lh�.L I�i J�SIIJIV <br /> PKG. TREATMENT PLT. ❑ CMeethod of Disposal \ <br /> Distance to nearest: Well Foundation Property Line <br /> TEACHING LINE O No. 8 Length of Ii Total length/size <br /> FILTER BED O Distance to rest: Well Foundation Property Line <br /> --EEPAGE PITS I I pth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> ISPOSAL PONDS O <br /> 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 /> 7ules 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 /> 'nploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> irtifies 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 compensa- <br /> --,on laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> igned X Title: Accent for Owner Date: 12/29/93 <br /> FOEPARTIMENT USE ONLY <br /> Iication Accepted <br /> pp spted by Date yA � ���'"'�V� Ares <br /> Grout Inspection by Date Final Inspection by Date <br /> `dditional Comments: <br /> A plicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services l � . l <br /> 445 N San .Joaquin, P O Box 2009, Stkn, CA 95201 <br /> r� INFO AMOUNT OtJE AMOUNT REMITTED C K N RECEIVED BY DATE PERMIT'NO. <br /> ;.,7.21t11IN.r,hsr 5� �R ISU � , 6DJ�a�� 2� 4a,Qoc� <br /> 1124 <br />