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UNTY PUBLIC HEALTH SEl'�`VICES. <br /> SAN J06QUIN CO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in 'triplicate) <br /> Application is hereby made to Saa Joaquin County for a permit to construct andd 1 install the work herein described. This <br /> application is made in compliance with San Joaquin :County Ordinance No. 5k9 and 1$62 and the Rules and Regulations of San <br /> :CS <br /> Joaquin County Public Health Services. <br /> Cary Lot Size/Acreage <br /> Job Address _ 4(c) caiti ti <br /> " <br /> Owner's Name f � "� s <br /> �lOg t ,� <br /> ll y C l i�tJ�l.} <br /> Contractor , <br /> .a \�1L�i Address ry License No. � <br /> ,, ,.� — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION c) out of Service Nell <br /> PUMP INSTALLATION ❑ ". SYSTEM REPAIR ❑ OTHER <br /> 'Monitoring Well <br /> SEPTIC TANK _ SEWER LINES }�^ DISPOSAL FL PROP..LINE Tt <br /> DISTANCE TO NEAREST: ``=�..,.�LL <br /> FOUNDATION AGRICULTURE WEtL�l�is �OTf�ER WELL PiTSlSUMPS � + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT10 SPECIF ATIONS f� <br /> 0 Open Bottom ❑ Manteca �'`-Dia. of Well E cavation <br /> Dial, We Ca ing <br /> ❑ Industrial 1 <br /> Types of Ca n -� specific on <br /> Cl DomestictPrivate �ravet P ck Tracy 9 �-� <br /> Cl Delta Oepth of out Sea ype o Groff <br /> Fl Public h]ILOiher ,i I IrriOation pro■. Depth I 1 Eastern Surface Se1r nst led bRepair Work Done C7 at PumP. State WoDne <br /> Weft Oes[ructian Clell Di <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJAODITION I I DESTRUCTION I I lNos pttiw shin system rented if public sewer is <br /> availaInstallation will serve: Residence— Commercial — Other <br /> x Number of living units: Number of bedrooms . <br /> Water table depth <br /> t Character of soil to s depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> s DISPOSAL PONDS ❑ <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 sub-contracting 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 compensa- <br /> tion iaws of California." <br /> The appfica ust call for alluired inspections. Complete drawing on reverse side. <br /> Mq <br /> Signed Title: Date: <br /> FOR DEPARTMENT'USE ONLY <br /> Application Accepted byDate S t Area <br /> Pit or Grout inspection by ? � .— Date �( 3 �T-- Final Inspection by_gLka�Isxf Date « { <br /> �.- <br /> Additional Comments: */I" P,4-4Z'uclL'e42---� jLu <br /> Applicant - Return all copies to: San JoaquI County Pu is Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box .2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> . EH 13.241REV.r/n31 �' L s� _ �'+� Sr+' [`/c [[+ y �' •• �Z J.� (( <br /> EH 14.211 <br />