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APPLICATION 'OR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIIENTAL HEALTH DIVISION <br /> 445 N SAN .JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 952.01 <br /> PERMIT _�MRES 1 YEAR FRQ DAM_1ff <br /> (Complete in Triplicate) <br /> Application ix hereby made to 8Joaquin County for a permit t; construct and/or install the work herein described. Thi. <br /> application Ili side in corrpllaace with Ban Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of Ban <br /> Joaquie Cou�nty. .PuIb�lic Health <br /> .itces <br /> XJobAddress Ave ..- •C �0." Cty SQG/Lrlrl Lot Size/Acreage <br /> Vl .-s Name a ELt - <,,�54y <br /> Phone <br /> O��vF <br /> ✓Conlracta � Address^ _License No. Phone <br /> TYPE OF WELL:PUMP. NEW WELL G WELL REPLACEMENT rl DES7 E�TO ❑ Out of Barvice Wall <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER G IbnLtoring Well U <br /> DISTANLi TO NEAREST: SE?TICTANR— y$EWER LINES DEPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU EkL OTHER WELL _ PITS/SUMFS <br /> INTENDED USE <br /> TYPE Of WFII PROpLEkf4REA CONSfRUCT11ON MtFiCBTIONS <br /> D Industrial L,0{tin Bosom Manteca Du of Wall Excavation �_��Oia,_of Wsll Cie rp <br /> C Domestic/Private G GnivelyaCk 0 Trncy Type of Cas.nQ__ __ Specifications_ <br /> I'I Public rl Delia Depth of Grout Seal _ Type of Grout.__ <br /> IrrrOaliOn A,atw ax. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work 0 nn U Type c!. H.P. State Work Done <br /> Weil Dostrxllon G Weal m <br /> Diaeter _ 9esling licterlal a LDrp h_J <br /> Depth_ _ Filler Hater !4 Depth <br /> _ <br /> `TYPE OF SEPTIC WORK: NEW 1NSTA,LATIO! c PAIR;ADDI'r10 J 1 DESTRUCTION INo pne system permitted J putHre 4a✓•'erTl <br /> \_ vada N within 200 feat.)�-� <br /> Inst&41 rve: Residence __ Coro - _ Other <br /> Numtbr of Hwang urn Number of lay'. <br /> Character of gall to a dz»th o TIWL• Water table depth <br /> SEPTIC TANK G Typ-/Mll; , Cspacit _ No. Compartments <br /> PKG.Tf:EATMENT PLT.G Method of Disposal <br /> Dgtart,'a to natrest: Well rounis6on Property Lino , <br /> LEACHING LINE CI No.6 Length of line <br /> FILTFR BED CJ Dist.enert to est: W&U Foundation rty Line <br /> SEEPAGE PITS 1-+ 0' apth ___ $ire_______ Number <br /> SUMPS LI Gisiancs to newest: Wall Foundnuon _ Property Line <br /> OISP PONDS CJ <br /> P"fiaretry certify Thai I have pra;iared thin application and that the work will L-done in accordance with San Joaquin county ordinances, state irws, and <br /> rube and rogulalions of the Sin Joaquin County <br /> Hone bvw.w or bcenaad tyent's t;gratu'e ryrlif,et The lotowing: "I certify that in the perlorrnanca of the work lot which this permit is isaudd.I shaft not <br /> employ any person in such menrw as to b4cone subtest to workmen's compensation laws of California"Contractor's hiring or subcontracting signature <br /> certrfres the forow4n,2:"I Certify that in thn liertsrmance of the work for which this permit a issued,I sial;emp:oy persoos subject to Nvorkman's cOrnpansa- <br /> lion la vs of Cavi!pp//rr/�{/�//��;; <br /> .' Tho spill artt mw or all required Inioectt'ans Complete drawing on reverse t;de. <br /> X $iarNdX ]j�Yr �t.�_J��'t�,�-`--✓ / Title: &_o r'.i7,,.,r 1'L�, .Cn'r�._.i- Dats: J 7 T.3 <br /> ' \ / FOR DEPARTMENT USE ONLY f> <br /> Appl::ation Aeceptee by _ .. _:� - Date7 - <br /> PIT of Gran Inswtion by _.�_ Dsa (— Final Inspection by ` Date 51�� <br /> Addivkrral Conwnert.: drPSS T'S."tISO <br /> ,ipplicant - Return all copies 10: San Joaquin County Public Health Services <br /> Soviroomentr.l He►1tl, Permit/Services <br /> 446 N San Joaquin, P O Box 2000, Stkn, CA 95201 <br /> ffE AMOUNT DUE <br /> 13-24 <br /> RE:NtTTED ( RECEIVED by OATS PERMIT NO. <br /> _ <br /> •EM Iiia la[V.r:x u �- <br /> [v to is C <br />