Laserfiche WebLink
APPLICATION FOR PER1dIT � Q <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1/ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> +~_; P O BOX 2009, STWKTON, CA 95201 OCT 3 0 1992 <br /> 4 . <br /> k - (209) 468--3447 <br /> t PRUIT EXPIRES I YEAR PRQM DATE I5§UED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in couipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 1153 VoM dP_V ' J ++ L�1 <br /> Jl 1-.__ City 1 1C Lot Size/Acreage <br /> We Owner's Name `^ ,dress� �� — Phone `z� Z <br /> Contractor + '� DrJ Address .S M. r Al_ License No. u�) a01 Phone Q&S-8 <br /> TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT DESTR`UC_TIgN 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ n.� WWD Monitoring Well �( <br /> DISTANCE TO NEAREST; SEPTIC TANK EWER LINES DI OSAL FLD. ��G PROP. LINE /� <br /> FOUNDATION ER WELL PITS/SUMPS r " <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATI NSPV . <br /> 0 Industrial ❑ Open Bottom XManleca Dia. of Well Excavation� Dia. of Well Casing <br /> U Domestic/Private )�Gravef Pack ❑ Tracy Type of Casing__PVl_. _'Sc-A-0 specifications �� <br /> M Public 1-1 Other EJ �Delta Depth of Grout Seal Type of Grout ern <br /> M Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Ark Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION D INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will Residence Commercial— Other <br /> Number of living units: ber of bedrooms <br /> Character of &oil to a depth of 3 feet: ,ter table depth <br /> SEPTIC TANK ❑ Type/Mfg Capach No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Found, Property Line <br /> LEACHING LINE CI No. & Length of Total len US <br /> FILTER BED C1 Distance nearest: Weil Foundation Property L, <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOS PONDS ❑ <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, and <br /> rules and 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I cer4thate performance of thework for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws of or la." <br /> The apl: sl call fornspa o mplets drawing on <br /> reverse side. _ <br /> Signed Title: -JPj1' f 5� Date. 71— <br /> c <br /> FOii DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or G o I apectian by Date �=!5f�n FinaE Inspection by <br /> Additiono <br /> Applicant — Rat�nn all cop a o: g AQUIN CO SLIG HEALTH SSRVICSS <br /> ENVIRONMENTAL HEALTH DIVISION PSRMIT/SERVICER ��� <br /> 445 N SAN JOAQUiN, p O BOX 2008, 8TUCKTON, GA 95201 <br /> INFO AMOUNT OUE AMO(U�NT�REMITfEO CASH RECHVED BY j jOA7E PERMIT NO. <br /> . EH 13•741ltEV.IinS) � �. UT <br />