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APPLICATION' FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> "r ENVIRONMENTAL HEALTH DIVISION <br /> x, 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> [ P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) / 0_2>0 � <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> I application is made in compliancelwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r <br /> Job Address .City AL-It— Lot Size/Acreage <br /> Owner's NameY Address <br /> Phone <br /> 6�1 Esq <br /> r <br /> ContractoraLaLLa Eli Address License No. Phone �. <br /> #TYPE Of WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ Monito 11 ❑ <br /> DISTANCE TO NEARE PTIC TANK_ SEWER LINES DISPOSAL FLD. OP. LINE <br /> F FOUN N AGRICULTURE WELL " "¢'�"4` "` ELL- _ ITS/-SUMPS="""�'""'"'- <br /> INTENDED-USE- -' TYPE OF-WELL'^'«, , { ' _ <br /> ;_101Nr.SEECIFICATIONS -=----C7 �„ <br /> industrial �Indial <br /> ❑ Open Bottom n <br /> 4 <br /> a ❑ Manteca /'� II <br /> .� � - e Excavation Dia, of Well Casing d <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Type Of Casing Specifications <br /> V] Public Ci Other fn Delta Depth of Grout Seal ? <br /> Grout <br /> I I Irrigation pprox. Oepth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done r <br /> Wall pest n O Well Diameter ' Sealing Material i Depth <br /> .`s Depth. biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL`L'ATION I I REPAIR/ADDITION i I DESTAUCTION YNo,septic system permitted if public sewer is C <br /> = availible within 200 feet.) <br /> Installation will serve: Residence Commsrcial•^- >"Other - Jm <br /> Number of living units: Number of bedrooms <br /> Character of soft to a depth of 3 feet: I Water table depth . f <br /> SEPTIC TANK. D Type/Mfg 1 Capacity No. Compartments ! <br /> PKG. TREATMENT PLT.Q Method of Dispose! <br /> Distance to nearest: Well—.Foundation Property Cine <br /> LEACHING LINE ❑ No. A Length of lines Total length/size rn <br /> FILTER BED ❑ Distance to nearest: Well Foundation'��_ .. � 'Propri?ty Lind- *.: � r <br /> SEEPAGE PITS I I Depth # Sisa Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ 4 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San unJoaquin county ordinances, state laws, an ' <br /> rules and regulations of the San Joaquin Coty d <br /> Home Owner OF licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I$hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting-signaturs <br /> WWI the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The applies st ca r uir spa 'ons. Complete drawing on reverse side. <br /> Signed Title: <br /> Data: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted b L <br /> sP Y - — Dats�`�=�y.3-Area �jy <br /> Pit or Grout Inspection b � f-3--Area— <br /> Y Date Final Inspection by Date 4Z,7 R3 h <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services (.cwS K�f krtcw <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE AERMIT NO. <br /> INFO /!.{'— Aid CA5H <br /> • EM 13-24 IIIEV.11.Si 7 1'�� +� C, {J } <br /> EN 1476 I ` / ✓! <br />