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j' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y , Z <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 NOV f992 <br /> PSk` f �p� <br /> t PERMIT EgPIRES 1 YEAR FROM DATE ISSUED=+'U'vi ��� ��AHCUNT� <br /> (Complete in Triplicate) � r�T '_RiI,C�S <br /> iicat oa is here made <br /> If �i�J �,�,a,. <br /> AFP by �Barr Joaqu County for a permit to construct and/or install the vont herein described. <br /> application is made in catPllance with San Joaquin County Ordinance no. 549 and 1$62 and the Rules and Regulations. of San c <br /> t Joaquin County Public Health Services. <br /> Jobd�AP uy - AF tbeay AP/102 V--Gi3 <br /> ..._.,.� CityMAArIFr4 Lot Size/Acreage <br /> k Owner's Name Address one <br /> I <br /> Conti acto DOWAIK Address 0 S d License Ifo.t3�l phone667- U2 <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT .1 DESTRUCTION ❑ Out of ServiceWell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION ~ AGRICULTURE_W_WELL OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> n Industrial O Open Bottom Manteca Dia. of Well EYcavadon Dia. of Well Casing D, <br /> El Domestic/Private ;t�Gravel Pack ❑ Tracy Type of Casingf6qiSpecifications <br /> i'1 Public . !'1 Olhef• •- n Delta De th'of Grout Seal '�T- <br /> �__ - - - A v26�0-:.; p W'� Type of Grout. LTi? /rF <br /> >�hrigation �Approxi Depth I I Eastefn+n Surface Seal Installed by <br /> Repair'Work Done L3 Type of Pump H.P. State Work Done w <br /> WON iDiestruction' O Well Diameter' Sealing Material & Depth <br /> E Depth ."�2 ti f Filler Material i Depth <br /> a <br /> • TYPE OF SEPTIC WORK: NEW INSTAL", ION f I REPAIR/ADDITION I ! DESTRUCTION I I INo septic system permitted if pubiicsewer is <br /> available within 200 feet) <br /> Installation will serve: Residence—! Commercial Other [� , <br />'i Number of Nving units: Number of bedrooms } \ i ► <br /> 'Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg ` Capacity No. Compartments <br /> PKG.,TREATMENT PLT. 0 Method of Disposal <br /> Distance to.nearest: Well <br /> Foundation Property Line <br /> a <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well " Foundation Property Line (� <br /> t ` ` <br /> SEEPAGE PITS 11 Depth t Size Number <br /> SUMPS <br /> LI Distance to nearest:, Well Foundation ;Property Lina <br /> S OSAL POND ❑ t -sI <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, end <br /> rules'arid 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 shell not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 lives of California." <br /> The applica st II or all uired ingmptions. Complete drewing on r rse sid - I <br /> -^'Title: 'Date: <br /> FOR PA ENT US NLY � <br /> Application Accepted by —�, <br /> Date �Arsa <br /> Pkrout n � � ! <br /> spectlon by Date incl Inspection by Date <br /> Additional Comments: IL <br /> r <br /> Acant• Returp al copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> F 445 H San Joaquin, P O Sox 2009, Stkn, CA 85201 <br /> f EE AMOUNT DUE AMOUNT REMITTED RECEIVED Y D TE PERMIT'NO.'' <br /> INFO C H <br /> . EH 13-26 fREV.riRa1 �y ! S/ <br /> EH 14•20 � r GSC/ CJ` <br />