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<br /> SAN JOAc UIN COUNTY PUBLIC HEALTH .;E#i S-� OP y
<br /> _3S
<br /> ENVIRONMENTAL HEALTH DIVISION '
<br /> 445 N SAN JOAQUIN, PHONE '(209)4 8�
<br /> P G BOX 2009, STOCKTON. CA 9 ZQl L-✓
<br /> PERMIT U,,PIRES I Y R JEROM DATE 13 (`
<br /> (Complete in Triplicate) f U
<br /> Application is hereby erde to San JorQutn Cibunty for a permit to Conntruct and/or .TFt8lj-tfrC••reFJrnh9FSl� r".'+ r '
<br /> application is made in eosp1lance with Dan Joaquin County Ordinance No. 54 oral 16c2 asa_the Rules and Resulatlonn oT pan
<br /> Joaquin County Public Health services. P�
<br /> C ( ;;,C+t ul xr%AG rc agr
<br /> �h. Jot Address -Y
<br /> i
<br /> owner's NamA
<br /> _ _:_ Address _ Phone `'
<br /> 1 } ^
<br /> Centracto Asaress.'�V� -�l� - "tr r:o. �.< Phone 1.� �d-
<br /> TYPE OF WELL UMPti NEW WELL C, '•fEIL REPLACEr.1rNT f DEST.rUCTION i�l Out of Srtrvice Fell p
<br /> d PUMP INSTALLATION C SYSTEMREPAiH OTHER L, Ll Well (7, -
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ 1:;�•"OSAL rLD.- PROP. LINE .
<br /> FOUfJDATiON AGRICULTURE WELL __ OTHER WELL___ PITS1SUMP$W.=
<br /> i,:e1•is. -e -
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP9rIpICATIONS� �
<br /> _.� -- - ----. ~--.— De.of Welf Casing i
<br /> r.I Ind u al C3 Open Bottom u Manteca D+a.of Well E:cavallon
<br /> L�F f+h Ofl16alicl Private 0 Gravel Pack l]Tracy Type of Casing T_- _.._—._._..� %Deca,cail.ons
<br /> ° '„r.• ,"_ Type of Grour_ 1.`
<br /> ♦z n I'1 Public [;l 011ier r Dena Deprn nI Grain Sea: IV
<br /> ` „(^
<br /> 11 Ifilualron i Approx. Depth I I stain Su,-face Seal mst.11yd bv._T 1
<br /> ” r Repoir Wars Done Type of Pump State Worl Done `
<br /> N Sealinti ffaterial i Depth
<br /> fF {'. West Destruction Q Wet/Diameter
<br /> lis Filler Katerial i Depth ?'
<br /> DRP 1.
<br /> ,,t TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADOITION i I DESTRuCT1ON I i INO septic syuem parmilied J pi,bbc sewer is
<br /> s,^•.,,,�. r' awlFable wnttn 2W feet.) :
<br /> Installation who serve: Residence— Commercial ^ 'Other�—
<br /> .I ' Nuntbar of livrrsg units: Number of badrroms
<br /> a� Chmacler of soil to s depth of 3 feet: _ _Water table depth
<br /> >. , - T _ CaUaelty No. COmpartmenes .
<br /> k ` SEPTIC TANK' O wolMlg '
<br /> PKG.TREATMENT PLT.0 Met od of Disposal y
<br /> Distance to neer .t: well Fol.ndat'on Property Una _
<br /> �g E LEACHING LINE [1' No,3 Length of tines Toro/longtnlsire_ _.
<br /> FILTER DED r] Diatancs to naefssl:
<br /> Well Foundaton Progeny Lina
<br /> a
<br /> ,.6 "" „: SEEPAGE PITS: .1 1 Depth Sire Nunber
<br /> ,.
<br /> i'".r"'. :_' Yl'"�^r, a ' •z
<br /> _ Property LinaWolfSUMPS LI 7istaneto noaat: FOundalior
<br /> DISPOSAL PONDSr ❑
<br /> I hareby cenify thatve,I hapreparad this■pplicatton and that the work will be clone in acrordanca With San Joauuin courny adirances,state law's, and {
<br /> rules and r"IsiNss of the San Joaquin County
<br /> Home Owner or Itcensed agent's signature certifies the foflowing:`1 cenify that in the perlamnncs of the Mork for which this perrrat K iatued,.l shah not
<br /> 4 i'f L} 1F': employ any person in such mertnsr a to oma 1 blect to wor►man's compensation laws of California."Contractor's horn f of suc w„rracl•no Donarare
<br /> , I.,;, A`-t 1 'r certifies 1M toeoyring:"I cenify that in tM ormanea of Ctrs work lot which this permit is issued•I Shall smploy fieraona auD;.cI to workman's componaa i
<br /> Iion 4ws o}Celilw z
<br /> eta drew r aldol - '
<br /> a t rrw tae}or ail r � w f .Comp/ +rtg on
<br /> ro sr, g 1 Y
<br /> �) .:,.t'•:,i� ti`
<br /> Data
<br /> e.''cri.;+'i` •f A Signer/
<br /> it__
<br /> vlr 1` a r
<br /> FOM DEPARTMENT USE ONLY
<br /> Dale Area L 5,
<br /> ADWtbn ACCtM+ted 6Y - it.
<br /> e r Ph or Grout Irt�Jeetion qy Date Final Inspection by Dau
<br /> 1 rr•,�!!r
<br /> ndfJ'?!'1s41c+�. c Addhbnol Comments: —. `5
<br /> "r - ltpplicantU Return all copies to: San .lrtaquln County public Health Servicen �: +
<br /> �•yh tievlronmontal Health Pe+rmltltiervlcoa
<br /> ei .a l f a rh r 445 N Son Joaquin, P O 110K 's 004, Htkn, CA s7g201
<br /> �• R
<br /> AMOUNT DUE AMOUNT P#MITTED- RECEIVED By DATE PERMITND.
<br /> ' •� ,aMr(/p /y7 ' Jttn,' .LII/ /L�
<br /> $174 IaEV..rear fir• ,� J I r ./ � I I�� >u':
<br /> �' S A'kl .•,.• �� F, �;:f zl^.+:naa�nr+e....,raw-> ,.r n.,.:a� R�r•...x x.,.::...Y'��. ... .. ,»..-• �.. .,.. �...-. .:..w:wer r'Sr..F,`r',((yk.Hn. '%,:,
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