Laserfiche WebLink
r � N <br /> SAN JOAQUIN COUNTY P LIC HEALTH SERVICES <br /> ' ENVIRONMENTAL TH DIVISION � . <br /> r` SAN OACOUNTY. <br /> N PH 209 468-3424 0 Q <br /> � Q�����PUB�� STQCgTON( CA)95201 <br /> ENVIRONMMNTAL IMLTR W , , <br /> SPECIAL P IafildIDIRES 1 YEAR FR <br /> r (C omp t e t e i n T. .i p l i c a PUBLIC HEALTIi SERVICES <br /> ONMENTAL IM41TH DIVISI�N <br /> Application is hereby mede.to San Joaquin County for a permit to construct and/ k sin describe . This <br /> application is made in compliance with San Joaquin County Ordi nce No. 549 andU ,teAk P�i�u i$ of San <br /> Joaquin County Public Health Services. _ ;�u1r I <br /> Joh Address City�� Lot Size/Acreage GpA�� <br /> r C <br /> Owner's Name Address Phone <br /> Conti actor 6LA.Y_ _5Pc f %Address: License Phon61 <br /> TYPE OF WELL/PUMP: ,f NEW WELL O WELL REPL ' EMENT 5 / DESTRUCTION Ll Out of Service Well D <br /> --PUMP iNSTA'L ATION�❑ —= �+- WELL <br /> REPAIR_❑ f OTHER-r❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES LCL BEd •E�( E _ <br /> FOUNDATION AGRICULTURE WELL �i- I �NE@wfiLeaq in St_. PITS/SUMPS <br /> iNTED USE TYPE OF-VVEL"L`�'""'"PflOBLEM AREA CdIVSTRUCTION 9P LPPROVED Gl i - <br /> ' �'i T0: <br /> El <br /> L-1 Industrial O , rT f Well Excavati alllfa raw",Basing-- <br /> . [I Domestic/Private G ��rtlty�`+�; of Casings B. Q�}tS[l11`O E��:It?T(���I�tierrs � n <br /> I'1 P rbhe.• i.l IAIQ HJ.T��rjO'HMN3f Grout Seal C:_fora natr-•! Types of Grout n <br /> ' 1 i IfOu ion ST <br /> �.I +IIp,�. �IZHCLd._e�tT.Nl1.00.awhli'eLw$a�n <br /> Repair V1�o.r�k Done L] Type of Pump H.P. k Done ` \ <br /> Well Destruction ❑ Well Diameter , F Sealing Material i Dep <br /> T <br /> Depth F Filler Material 6 Dept <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 _ REPAIR/ADDITION DESTRUCTION mi ad it-Public it—Publicsewer is <br /> I, �, " , , ` �;i..e -_,available within 200 feet.) C� <br /> _ '..Inatailation will serve: Residence X_ Commercial Other Date by f <br /> Number of living units: �_ Number of bedrooms } <br /> ` Character of soil to a depth of 3 feet7,,,' A Water table depth <br /> SEPTIC TANK. O Type/Mfg ,_ � t3> i�apacrNo. Compartments <br /> *}P G TREATMENT PLT. Cl � X r C�$ } Method of Disposal <br /> r : SANOAQUIN( ?3t �&c�slC Foundation� Property Line <br /> NVIRONMENTAL HEALTH�D V� <br /> LEACHING LINE' L�'tfii o Total length/size ' <br /> FILTER BED Is ante To7inearest. Well Foundation Property Line .0 <br /> SEEPAGE PITS a �I I "'depth ' Site ' Number <br /> {'~ SUMPS` �' ' . LI Distance to.nearest:,;... Well Foun Line ' <br /> _ ..yDISPOSAL PONDS —❑ I. d 6 x M -MLIC'MMSER <br /> Thereby certify that_I,have prepared this application and that the work will be done in acco' ante with an D&Wl$dcalate laws, and <br /> a rules Arid regulations of the San Joaquin County ' <br /> Home owner or licensed agent's signature certifies the following: "I chat in the pert I <br /> formanc r Issued, I shall not <br /> 'employ any person in such manner as to•become-subject;to workman'sib rlpensation laws of California." Contractor's hiring or 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 laws_of,California.',:, <br /> The applicantMil call for all,�yifAd ns',, ions. Complete drawing on reverse side. <br /> Signed X_ �> 1C �I;riL!��Title: � � 1 Date: <br /> FOR DEPARTMENT USE ONLY Q , <br /> Application Accepted by _.� a� _ 4 Date � r I„L Area <br /> Pit or Grout Inspection by Date Fir1�'�I]1��1 � OateB_'�Z <br /> w I'UBI,IC HEAI.7�r <br /> Additional C mmerts: <br /> qq VISION <br /> App li n�- t1�tu n a copies �an oaquin C �rn` b is Healt <br /> Environmental Health permit/Sery A1- PEY� }�,6j T <br /> 495 N San Joaqufn";"{P O Box 2009, Stkn, CA S52 ��j1{r�g <br /> INFO FEE <br /> AMOUNT DUE [ AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. N_ .1 <br /> . EM1324IREv.rin5i <br /> EH 14.20 <br />