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APPLICATION <br /> t SAN JOAQUIN COUNTY PUBLIC HEAL �D <br /> ENVIRONMENTAL HEALTH DIYI �� <br /> 445 N SAN JOAQUIN, PRONE (209 <br /> P O HM 2009, STOCKTON, CA <br /> PE S Y FR M DA R <br /> (Complete in Triplicat ) <br /> Application is hereby made to Sen Joaquin County for a permit to construct end/otr install the work herein des—Mr-M.I. <br /> ayplication Is made in coeVltance with Sera Joaquin County Ordinance No. 549 and :1862 and the Rulea arta Regulations of flan <br /> Josquia County PuLllc Health Services. <br /> Job Address _ City I.,ot Size/Acrcr%ge <br /> I <br /> Owners Name Address A —�. _ Phone <br /> I <br /> I <br /> Conti &A-allL 0fir' iuense �' Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well. Q <br /> r <br /> PUMP INSTALLATION Q SYSTEM REPAIR 2-11 OTHER ❑ Manitorina Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLU. PROP. LINE ;-. <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHFR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ! n Industrial a Open Bottom ❑ Manteca Dia. of Well Excavation__ Die, of Well Cating <br /> C r estittPrivate ❑ Gravel Pack 0 Tracy Type of Casing__ Speeifications <br /> I.1 Public fa Other f7 Delta Depth of Gmul Seal Type of Grou <br /> r I Inigatron Appro><. Depth 1 I Eastern Surface Seul fnsiafled by T <br /> t Repair Work Done !d' Type a1 Pump . , H.P,f;�.— State Work Oons <br /> Well Destruction ❑ Well Diameter Sealing PAterial i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRrADDITION I i DESTRUCTION f I INo septic system permitted if public sower is [-A <br /> availebfe within 200 feet.! 0 <br /> tnstatletion vvrN se+ve: Residence!. Commercial— Uther v <br /> Number of living units: Number of bedrooms tA <br /> Character of soil to a depth of 3 feel� ite,fable <br /> I <br /> SEPTIC TANfR 0 Type1Mf9/Mig Capacity ..�, o <br /> ' PKG. TREATMENT PLT.❑ <br /> V Distance to nearest: Wait Foundation— Prop <br /> iP noOA e�+} <br /> -- - <br /> LEACHING LINE Cl No. 6 Length of Eines ToinIF1 0I <br /> k I FILTER BED ❑ Distance to nearest: Well Foundation �I R l� TFf <br /> I L7fd <br /> SEEPAGE PIPS 11 Depth —Size_ Numbar.. <br /> SUMPS LI Distance to nearest: Well Foundatian Propeny Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance ierith San Joaquin county efdinantes, state laws, and <br /> i rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance Df the work for which this permit is ifs ,f Shall not <br /> employ any person in such manner as to become subject to workman's compensation lavua of California."Contractor's hiring or suh contracting signature <br /> certifies the fallowing:"r certify that in the performance of the work for which this parmit if issued,l shale employ persona subject to warhman's compensa- <br /> tion Sawa of Cafifornia." <br /> The applicaht/mg all required ins eCtlons. Complete drawing on rSverse side. <br /> Signed X Title: _ Dater <br /> T` <br /> FOR DEPARTMENT USE ONLY L <br /> Application Accepted by Date <br /> Pit or Grout Ir,tipsetion by Date _— Final Inspection by_ s MDate - <br /> Additional Comments: <br /> i Applicant - Return all conies to: Saa Joaquin COLntp Public health Services <br /> . Environmental Health Permit/Services ��� <br /> 445 N San Joaquin. p D Box 2009, Stkn, GA 952 <br /> FEE <br /> INFO ^ NT DUE AMOUNT REMITTED K RECEIVED BY DAT PERfWIT'NO. <br /> fH77-2A f1rFY.ilJIsl ♦ I <br /> EH �^ <br /> teal ! {/ <br /> 1 <br />