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PERMIT EXPIRE APPLICATION <br /> AN OAQUIN COUNTY PUBLIC HEALTH SER IC -- -- <br /> Permit may have expired wit�iou�` ENVIRONMENTAL HEALTH DIVISION <br /> work being completed or inspecte#5 N SAN JOAQUIN,PHONE(209)4691342 AID <br /> P O BOX 388, STOCKTON,CA 95201-0388 <br /> by Environmental Health Division FAC #. <br /> PERMIT ESPIRES 1 YEAR FROM DATE SS <br /> (Complete in Triplicate,) IV, . <br /> r Apelcattoti is hCG1)y�rilade 30 San 7byllin County€or:a permttftncanstruC$nd/ar 'ttsta thYe orhetin destribad T1[tsyp¢Iltton is rnada urttgrtlliance with San <br /> '.Joaquin County llCvaloprr#ent Ti <br /> 3.and Sec Tori 1115.3'and the.>ules and tt`egulanon's of Sait,JoagmnYzounry P bltc Health etytces. <br /> Job Address City Lot Size/Acreage <br /> Pa"L MoeAaA ti,., � <br /> Owner's Name - Address no <br /> - l i <br /> n � <br /> ' mak. is I •'1V <br /> -x <br /> Contractor �s � � �MET'T License No Phone <br /> f TYPE;OF WELL11PUMP: NEW WELL ❑ WELL REPLACEMENT (-i - - DESTRUCTION ❑ but of Service 'tali , 0 <br /> PUMP INSTALLATION G SY_STEM"REPA - OTHER. ❑ ,._)Monitoring wf:ell <br /> 5AL FLDDISTANCE,TO„NEARESTt_.SEPTICTANKfiSEWER LINES 0 !. <br /> C� <br /> Pf10P. LINf <br /> -..,y <br /> FOUNDATION AAGRICULTIjRE 11VELL OTHER WEI:L PITS/SUMPS s <br /> = z.- - ; <br /> INTENDED USE TYPE QF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS t <br /> -0 inausrrrsl ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation i <br /> I 1 Domestic!Private ❑ Gravel.Pack ❑ Tracy Type of Casing- <br /> 11 <br /> asing_1"1 Public ' (-.I Other A.­ ; f7 Delta Depth of Grout Seal ype o Grout <br /> I�I IfriOation Approx. Depth I I Eastern Surface Saal.lnstalied by r.• SAN JOA-OUIM <br /> Repan Work Done U H Type of Pump g.1. xH P M State Work �Q�11 <br /> _ _. :. t _- <br /> 1 Sealing MatCr1"al i 1]epth <br /> ' WeII,Destructron �❑ Welf Olarileler ' ��� - <br /> g r s r•. 1 <br /> h_ W. al Dep.th� ? Filler Mteri.Dept - [ - <br /> t <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION; INo septic system paimitledif public sower is -- <br /> s �. z .; a __F•. w h .w. ..,_ �A `:` available W0000G, ?. <br /> lnatsllauan wi11 sortie: ,Residence�'r;Lia Commercial= .Other 1' �* t y <br /> Number of living units Number of bedrooms a v <br /> Gharacte.r of boil to a; pt <br /> J �a ^~ ` Water fable depth' ' <br /> a <br /> SEPTIC TANK ,.51 ; <br /> . .: ,. �. pacify No..Campartlments_ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> _t Distance to°nearest: Well �_ Foundation rProperty Line <br /> LEACHING LINE ❑ No. b Length of lines ToleI length/sizeF <br /> FILTER BED -•k --n Distancelo"~nearest: Well Founaation mP�opertyLtne"' <br /> SEEPAGE PITS I I Depth Size Numhar <br /> SUMPS - LI Distance to nearest: Well Foundatioh, ` - Property Lina - <br /> DISPOSAL PONDS D t' <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, itate laws, and <br /> rules and.ragulations of the.San Joaquin.County -.•-;.. _ _F. I . - <br /> Home owner or licensed agent's signbture'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-contrscting'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 io workman's cpmpansa- <br /> tion laws o1 California.” ! <br /> The appti a t must call fo I required i spections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY r- <br /> ApplicsVon Accepted by Date 1'7 N Ares h . <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: _. <br /> Appl ican-t - Retui:n"'all copies :to; . 'Spn4 a-4diii'Couri•ty Public Hesltti Services <br /> Environmental Health Permit/Services <br /> 4,45 N."San-Joaquin;P.O.-Box 388;Stockton;CA 95201-0388 <br /> I�FQLT�IUIE <br /> AMOUNT REMITTED � m RECEIVEDBY ( DATE PERMIT`NO,EH 14.26 �� �+l �✓ <br /> EH 13.24{aEv,11 n 61 r d <br />