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APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 2009, STOCKTON, Cg 95201 <br />1 ( 209) 469--3447 <br />l <br />(Complete 1n Triplicate) <br />Application is hsxeby aaarla to San Joaquin County for a hermit to carrtruct and/or install the vork herein dest:ribed. This <br />yrglicatiou is made In towplisne'a vith San Joaquin County Ordinance No. 549 aaad 1$62 And the Itulea and IttgulAtione at San <br />asquin County Publirc <br />-►Health beeryicea. �y /_ �j� <br />Job Address t4> 1 tJ i �ii r2S✓�� Cit,r '' lot Sites/Acreme <br />/ I herabY Certify IhM I have Prepared this appliCatian and that the work will be done in auotdarr.# with Som Joaquin county ordinances, state Saws, and <br />,saint and regulations of the San Joaquin County <br />Hoose owner or licensed agent's signature t omifitat the foNawinq: "I certify that In the performance of the work for which this parmit is issued, I shad not <br />ampioy any person in such manna as to become subisct to worlimsm's conmpenstlion laws of California." Contractor's Hiring Of sub•Contracting signature <br />aertifias the foNowing: 'I Csttlfy that in the perfarrrusace of the work for which this own—it is istutd. I shall emoloy parawu subi"t to workmats'a carnpsnsa• <br />tion laws of California." <br />IkThe apptiearvt mat coil for ail nrquirad inspections. Comptes drawing an rsysrss aids. N w y <br />5,9ned Titin L2tji A Date: <br />w `..y....�..'421a=tt...— <br />DEPARTMENT USE ONLY <br />m q_ <br />Application Atcopted byDaie <br />Pit w GfOut w4wtionG" <br />bV final Inspsc6on by , y I rl.✓ Da" 71,E <br />Additional Comments: <br />Applicant - Raturn all wVies to: SAN JOAQUIR CtRiN" PUBLIC IIBALTS SYRVICSS <br />ENVIRONMENTAL RRALTH DIVISION pYlttlllT/SRRVICSS <br />445 It SAN JOAQUIN, P O BOIL 2009, SWUTON, CA 06201 <br />• tN 13-N IREV. —4 5i <br />EM 71.A <br />fEE <br />INFO <br />AMOUNT Oi3EAMOUNT <br />thvr»r'a Nims <br />: 12 LZZZI– Address ZIS 51116)y �/� Phone Zi <br />Contractor <br />DATE <br />rALE <br />License No, fton t <br />T of OF WELL/PUMP. <br />NEW WELL Cl' • ti \ WELL REPLACEMENT r . 4OE5TRUCTIC) C) flat aY Sarvice Wo.21 Cl <br />33163 <br />PUMP IN5TALLATION'JrSYSTEtaI REPAIR C OTHEii D Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE <br />FOUNDATION . AGRICULTURE WELL OTF14R •Wet `'" r PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION-iPECIFICATIONS <br />C3 tndustriaS <br />0 Open Bottom 0 .r 't 4s, of Wall Esccrvrtid» Oia. of Well Casing <br />U O*MiisticlPrivate <br />_Mant -� <br />0 C'"a Pak Type of Casing 5pstaticstiam <br />rl Ptiblid <br />Ill 0 Debs Depth of Grout Seat Type of Grout <br />M IrriLl tion <br />_ Approx. Depth 0 Eastern Surf" Sus$ instaNsd by <br />Rs rk Dora 0 <br />Type of Pump H.A. State Work Done <br />Watt Deatruction O <br />Wall Diameter Sealing Mtterial i Dapth <br />"1tYPE <br />Depth 7I11or Wtorial i Depth <br />OF SEPTIC WORK: NEW INSTALLATION 10 RIPAif11ADOITION 0 DESTRUCTION 0 1No.septic system parmiited if ix+biic sevver is <br />amraifi�SiO wstttin 200 Iaart.I <br />Installation wiN save:. <br />,,.� <br />Reaidsnce °�' COnvft►r W Othw 1 '0 <br />Number of tivaV emits. <br />� <br />Nurrmbst of bsdraonm _ r <br />Character of oak to a depth of 3 teat: � - " m' Water tablet rteptn <br />SEPTIC TANK <br />i�Type/&iffy Capacity /J ,0 No. Compattmerits <br />PKG. TREATMENT PLT. <br />C3 Method of Disposal <br />Distance to nsar+est: Wal Foundation Property Line <br />LEACHING LINE <br />Na. S Length of liras ; "` _ Total length/Isito <br />FILTER BED <br />Cl Distances to monist: WON Foundation Property Line <br />SEEPAGE PITS <br />1 ! Depth' S $Ira Number <br />SUMPS <br />LI Dittanea to nosiest. woo Foundation Property Lire <br />DISPOSAL PONOS <br />O <br />/ I herabY Certify IhM I have Prepared this appliCatian and that the work will be done in auotdarr.# with Som Joaquin county ordinances, state Saws, and <br />,saint and regulations of the San Joaquin County <br />Hoose owner or licensed agent's signature t omifitat the foNawinq: "I certify that In the performance of the work for which this parmit is issued, I shad not <br />ampioy any person in such manna as to become subisct to worlimsm's conmpenstlion laws of California." Contractor's Hiring Of sub•Contracting signature <br />aertifias the foNowing: 'I Csttlfy that in the perfarrrusace of the work for which this own—it is istutd. I shall emoloy parawu subi"t to workmats'a carnpsnsa• <br />tion laws of California." <br />IkThe apptiearvt mat coil for ail nrquirad inspections. Comptes drawing an rsysrss aids. N w y <br />5,9ned Titin L2tji A Date: <br />w `..y....�..'421a=tt...— <br />DEPARTMENT USE ONLY <br />m q_ <br />Application Atcopted byDaie <br />Pit w GfOut w4wtionG" <br />bV final Inspsc6on by , y I rl.✓ Da" 71,E <br />Additional Comments: <br />Applicant - Raturn all wVies to: SAN JOAQUIR CtRiN" PUBLIC IIBALTS SYRVICSS <br />ENVIRONMENTAL RRALTH DIVISION pYlttlllT/SRRVICSS <br />445 It SAN JOAQUIN, P O BOIL 2009, SWUTON, CA 06201 <br />• tN 13-N IREV. —4 5i <br />EM 71.A <br />fEE <br />INFO <br />AMOUNT Oi3EAMOUNT <br />Ramal neo <br />K <br />CASH <br />� HECEtVEtI By <br />DATE <br />PEAM" INV <br />•oma <br />33163 <br />V� <br />