Laserfiche WebLink
03-03-1995 09 35AM FROM TO 19157867830 P 02 <br /> HYYJ.a 1 t.d 11 Vlr .-� <br /> SART JOAQUIN CODNTY PUBLIC HEALTH SERVICES ,c► ��>�F <br /> ENVIBOMMTAL EMALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC KION, CA 95201 <br /> PSRI�IT SSPIHBg 1 YEAR FROMDAIiE I SUED <br /> (Complete in Triplicate') <br /> �1ppa,icn[iva is Aereby made W Sala Josquia County for s Permit to coaatruct and/or insta.7.l the work heretnidescribed This <br /> �syplication la trade in osglisaae vith Ban Joaquin County ordinaace Ho. 549 and 1$62 sad the Rules and Regulatioas or un <br /> Joequin Cc%mt;r F'cthlic Ileo6lth Seii"vices. ✓s� <br /> Cttv <br /> Lot Sizelocreage <br /> f y� -- <br /> lop AddreSS1z 69" <br /> rn ] 4 �5 Phone <br /> Owner a Name Address ff D(�O)c�1� ✓tGOJZi C11 <br /> Contractor <br /> ,address License No _- Phone <br /> TYPE OF WELL/PUMPii <br /> NEW WELL Q WELL REPLACEMENT C, OFSTRuCTION �(out of Service Wei-I <br /> " P6MP INSTALLATION O SYSTEM REPAIi1 C OTHER C Monitoring Well C7 i <br /> pISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENOED USE TYPE OF WELL PROS LEAA AREA CONSTRUCTION SPECIFICATIONS <br /> C7 lndusrrisl ❑'Open Bortom D Manteca Dia of Well Excavation Dia of wad Casing <br /> Type of Cason Sperificalums <br /> C1 Domestic/Private C1 jGravel Pack 0 Tracy 9- <br /> ! 1 Public n oeita Oepth of Grout Seal Type of GrsUr — <br /> i I Ifripation Approii, Depth I I Eastern Surface Seal installed by <br /> y P Stal Work 9ne z"r' L <br /> Repair Work Dona L3 Tr'>• of Purtfp w <br /> Well Destruction P< w6a Dwmeler �._. $*"Ing Ieasrrial i Dep[h r` r l/t <br /> OelI h, <br /> Filler Material i Dept <br /> TYPE OF SEPTIC WORK NF.W INSTALLATION I I REPAIRrADDITinN . DESTRUCTION i I (No septic system tierrtutied of public suer Is 1'1 <br /> availaole wlhin 200 feet ) <br /> tailstiart sail! sarva Re3>Qersce_ Commercial— Other <br /> Number of Erring unng Nuntber of bedrooms i <br /> Character of sed to a deprni of 3 feel: Weser Iowa depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No Co mom( entt <br /> PlKG TREATMENT PLY D 1 Method of Dicoria <br /> jo stance to nearest Well �r Foundation - Property Lune <br /> LEACHING LINE CI �trto 8 Ler>gtll of tiinea Totat larigrh/alae <br /> FILTER SED C] ;Dls:ance to nearest Wed Faunoation Property Urns <br /> SEEPAGE ITS I I 1OeDtli Sire Nun►pes <br /> St1MPS LI lorsrarace to nearer Well Foundation i Property Line I <br /> i <br /> DISPOSAL PONDS D <br /> I-haneby eeraty that I neve prii Md th,4 sppkcation and that rhe work w-0 be cone In accoroance rwth San Joaquin county ordrnantei state wws and <br /> rules and rwgtrlatiorts of (pie Sin Joaquin Count? <br /> Noma owner or rica +sad swam s wgaature certifies the foaowing t certify that in vne performance of nie work for writen Crus perms Is issued 1 shall not <br /> employ any p+sr+ort irasuch t*ntr.nair ss tDitYecorrte Wbtect to warRman a corrsoeneation laws of Cai,fornra ContrOmi*es hwtng or sut�ccntrscting z ature <br /> candies the follvwwv I Corney Hitt in the podormarwA of the work tar which Mrt permit is issued <br /> I shall sn+pWy persons sualact to workmen a corrlpensa <br /> tion laws of Calitornta- <br /> TAe applicant must csil a inspections. Gornoote d►awing on re roe s+da <br /> S - 7�:v Title Date- <br /> FOR DEPARTM U$E ONLY <br /> Apphcaroon Accamea try Data Ares <br /> Pit or Grout InspeGzlon by I Date Final lnsf>c>drt by Date <br /> 4Pnal Gorhmae>td <br /> Ap2lc^nt - Return 417. copLes to Sia Joaquin env CasteLy Public Heaery cervlCc6 <br /> Eaviroameatai Healtti parmitlgsr9lces <br /> 44S H 8:: Jea.Quin. P 0 Box 2009, Sekn. CA 95201 <br /> nwtOVrrT Out: AniOUNT REMITTED CASH RECM610 Bk DATe PERhal No <br /> `F Page I JA <br /> INFO <br /> l <br /> w frac iiitr ,..si: _ <br /> TOTAL P 02 <br />