Laserfiche WebLink
APPLICATION FOR PSSIIIT i <br /> SATs JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNLSNTAL HEALTH DIVISION <br /> 1601 $. 13AZELToN AVE. , PHONE (209)468-5920 <br /> P O BOX 2009. STOCKTON, CA 95201 <br /> t (Complete in Triplicate) <br /> i Application ishereby made to Ban Joaquin County for a permit to construct and/or Install the work herein described This <br /> application is made is compliance vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquia County Public Health Services. <br /> 1A 000 Sq -P1 <br /> Job Address _ 1448 1a E1 Tbsado Street City c*^r��-k C Lot Ss:e/acreage <br /> Owroee s Name M Wt ok t nnA P r one r t i es Address Phone <br /> 95b50 95815 <br /> Contractor Address <br /> Licensee NO .in154A r K7 Phone t r <br /> TYPE OF WELL/PUMP- WELL O WELL REPLACEMEN' Cl DESTRUCTION ❑ Out or Service well 0 <br /> Monitoring Veil <br /> + PUMP INSTALLATION O SYSTEM REP/JR Cl OTHER O Mon ,, �I <br /> I DISTANCE TO NEAREST SEPTIC TANK N a SEWER LINES 5 _ DISPOSAL FLD�,.1i� PROP LINE �--Y OBS <br /> FOUNDATION ., <br /> --0 . AGRICULTURE WELL --L-)-- OTHER WELL--4�.— PITSISUMPS L-0- 6nual 31 <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT10i l SPECIFICATIONS WELL <br /> q6ndustr� raj 0 Open Bottom ❑Manteca Dos of Well Errcavauon�____�— Dia of Well Casing <br /> CI Damestic/Private 0 Grave!Pack 0 Tracy Type of Casing _ Specifications <br /> III Ptlblle 1 1 Other 0 Delta Depth of Grout Seal I" Type of Grout <br /> I I Irrigation w Approx Depth I I Eastern Surface Soul installed by — <br /> Aepair Work Done 0 Type of Pump HP State Work Done_ <br /> We"Deatraction D Well Diameter Seeding Material a Depth <br /> Depth biller Material b Depth <br /> TYPE-OF WORK NEW INSTALLATION I I REPAIR/ADDITION I I DES AUCTION I I ING septic <br /> available yet m perfretted of public sewer n <br /> fttsiallation will serve (residence— Commercial— Other <br /> N t faM of Rvinll units Number of bodrooms <br /> Chauaatw of wN to a depth of 3 feet Wi[ar[able depth <br /> SEPTIC TANK ❑ Type/Mfg Capaca No Compartmsnts <br /> iMethod of Disposal <br /> t PKf3 TREATMENT PLT ❑ <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE CI No 8 Length of lines Total langth/size <br /> FILTER BED Cl Distance to nearest well Foundation Property Lina <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest WON Foundation Property Line <br /> j DISPOSAL PONDS O <br /> I li,*0by eirtify that 1 have prepared this application and that the work will be done in eecar,ance with San Joaquin county Ordinances,state laws,and <br /> ruiisa and regulations of the San Joaquin County <br /> hernia aWflar at NCenaed agent's signature certifies aha folla"nng 'I certify that in the performance of the work for which this petrtlit is Issued.1 shall not <br /> army any Potion in such manner as to became subfect to workmen's compensation laws at Cakfonua"Contractor's hiring or subcontracting signature <br /> aaAftit ow lokwirrp '9 Certify that in tM part nce of the work for which his permit is issued,I shall employ persons subject to workman a convents <br /> Ilan to"of CdM&nla" <br /> i The appikent must or eN roqui In ions C ate drawing on reverse side <br /> a 891 <br /> { $� Title Data <br /> 8 FOR DEPARTMENT USE ONLY <br /> AppIIe01lon Accepted by -� Date Tr Area s�— <br /> Pk ar Grout Inaptlaion by 4 Data final Inspection by 0410 - <br /> tuWhlane6 Comments. <br /> i <br /> �flppllattslb - Return all copies to; Se irmntiHealth <br /> ces. EvionetalHealthPermit/Services <br /> 1601 B. Haselton Ave., P 0 flux 2009. Stockton, Ca 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEO C RECEIVED BY DATE PERMtl NO <br /> N O ` CASH <br /> 46M1324iRaY r.,aft <br /> EM lA so I <br />