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APPLICATION FOR PS �+p � <br /> SAN JOAQUIN COUNTY PUBLIC HE TICES <br /> • <br /> ENVIROMMTAL HHALTH DI 7�5 <br /> 445 N SAN JOAQUIOAQIIIN, PHONE (2 420 <br /> P O BOH 2009, STOCKTON, �5201 <br /> TIRES I YFI&R FROM <br /> (Complete in Tripli <br /> AFpliestlOU Is hereby mads to Ban Joaquin County for a permit to construct and/or itte .AbKLAp,_ is <br /> oyplication is &ede in compliance with San Joaquin County Ordinance No. 549 and 1662 abe the Rules and <br /> Jowin County PubLic Health Samicea. <br /> JobAddress �7 �r / / w%�dweoe+� 9d• City f/dcnrlfest Blie/Acre✓se /aNE0_-4Cv'o`T <br /> i <br /> Owrela Name 6210 4b <br /> b 1_4rdyh V Address "'Ve Phone <br /> �AAL-1—in- <br /> contractor <br /> �- <br /> Contractor l7II IY� 40 5adk Address X_'k)ktfAh! `License NO. a�r�� � Pnox <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION G SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FL_0._ PROP. LINE _._ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Na, of Well Eacsystwn_ OIs. of W%J Coaling <br /> n Oomestic/Privato ❑ Grove Pack ❑ Tfacy, Type of Casing, Specifications <br /> U! Public Cl Other fl Delta Depth of Grout Seal ` Type of Grout <br /> I I Irrigation _Approx. Depth I I Eaa_Hm Sudace 9" Insured by <br /> Report Work Ona ❑ Type of Pump H.P. State Wort Dov _ <br /> Wel Destruction ❑ Wer Diameter Sealing Material A Depth <br /> Depth Filler Material 1:Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITQN 1 1 D STRUC I N I I (No aspire system permitted if public oawar is <br /> • available vnthin 200 fall <br /> Installation will serve: Residence_ Commercu t_ Other Liftie!�dl <br /> Number of Wing units: __/_ Number of bedrooms 2— <br /> Character of soa to a do"of 3 feel: CG If f/ Water table depth rill""B"' <br /> SEPTIC TANK. ❑ Type/Mfg gN GAIT pI 6 Capw,iry L- No. Compartranta A <br /> PK6. TREATMENT PLT.❑ Method bf Disposal <br /> Distance to newest: YNatI. Foundation_ Property Lata <br /> LEACHING LINE PF NO. 6 Length of lime IF, <br /> talai length/sire ¢�i <br /> FILTER BED ❑ Distance,to molest: Well lA,r• Foundation _ Property iia <br /> l <br /> SEEPAGE PITS M DepthSrte -�'L•i ,y. <br /> Number_ <br /> SUMPS LI Distance to nwat: WON /___x Foundation /AIr' Property Lila :tee <br /> DISPOSAL PONDS ❑ <br /> 1 hereby unify that I have preened It"QPPlication and that the work vnll be done in accomance with San Joaquin county ordinances, stab Uwa, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or keno ed agent's gignttu t c tip the following: "I certify that in the performance of the work for which this Perrot is denied. 1 shad not <br /> employ any Person n such manner ce to become Subject M workman's compensation lave of Calitomea."Contractor'#hiring or tuiscontrocteng signature <br /> certifies the following: "1 certify thot in the Performance of the work for which this parent is issued, I shell employ persons subject to workman's compere <br /> tion late Of CallforNe." <br /> The a'patkcant VI call <br /> � e <br /> for aI,required inspections. Complate drawing ern ravaree ads. <br /> Signed K_aan4n tt7 Titer: Oats: //-/v"577 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accep!ed by � . Dns Ara 7 <br /> /// <br /> 7t In"Willon by Date �� Fine Inspection by Day <br /> Additional Cortunams. <br /> Applicant - Return all copies to: Sao Jeaquia County Public Health Servlced� <br /> N <br /> NOcIfOnOenttl Health Permit/Services S flan Joaquin, P p Boa 9000, Stte, CA 951NH AMOUNT DUE AMOUNT ITTED CASH RECDVED EY DATE <br /> /IV q�llF.H MN laty.v a ar 1 . <br /> EH"is <br />