Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 � <br /> E P O BOX 2009, STOCKTON, CA 95201 <br /> e <br /> PERU IT EXIrIRES�I YEAR FROM DATE Is�—Ul M <br /> (Complete in Triplicate) l <br /> c� <br /> Application is hereby made to Sar Joaquin County for a permit to construct end/or install the work herein described. This ; <br /> y' application is wade to eoWliance with San Joaquin County Ordinance No. 549 and 180 ami the Rules and Regulations of San <br /> Joaquin County ]Lblie Hee. h 8ervieea. �/� <br /> t �L� _ Crry11�K.L/_L �fe/A:reage i <br /> Job Addrafa g <br /> r —___ __ <br /> Owner's Name _ �1 address _ �L�--- Phone <br /> Gonlraescr ^'i.Ld/S ddress_ � �r __����} ���Ct�nseNo.�24(L Phone <br /> TYPE OF WELUPUMP, NEW WELL ❑ WELL REPLACEMENT -1 DESTRUCTION U Out or Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ;;' OTHER [] Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL___ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AGEA_ CONSTRUCTION SPiCIFICATIONS <br /> Ll Indu6trial a Open Bottom ❑ Manteca 0'a.of Wee Excavation_ — Dia. of Well Casing <br /> f.)Domestic/private CS Gravel Pack 0 Tracy Type of Casing.- _ Specfhcations <br /> °`- CT Public Ci Other 171 Detre Depth of Grout Seat Type of Grout 1 <br /> t� <br /> 11 hrigatlon —_Apptot, Depth I 1 Eastern Surface Seat Installed by f <br /> Repair Work pone 0 Type of Pump H.P, -- _--.„ State Work Done <br /> Well Destruction ❑ well Diameter Sealing Material ii Depth <br /> Depth Filler material i Depth _ I <br /> TYPE OF SEPTIC WORK: NEW lN$TALLATION I I REPAIRfADDITION tj_ApeSTRUCTJON I 1 (No septic system permitted if public sewer is <br /> 1 _ available within 200 feet.I S <br /> installation will terve: Res�ence YCornmeiciol_ Qther I <br /> _ x <br /> # Number of living units:, Number of bedrooms <br /> Character of loll to a depth-of 3 feet: Weinr table depth Ss <br /> SEPTIC TA14K L9ype/Mtq � Capacity No.Canpamnnts <br /> PKG. TREATMENT PLT.Ll C Method of 4iwoss! a <br /> Distance to nearest: Well���_ Foundation Property Line ,k <br /> LEACHING LINE Cl No.&Length of lima Total length/gird <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> i <br /> 3; <br /> SEEPAGE PITS 11 Depth ,..,•`Sita Number <br /> SUMPS LI Distance to nearest: Well__ Foundation _ Property Line <br /> DISPOSAL PONDS ❑ ff <br /> I hyteby Certify that I have prepared INS application and that the work will be done in accordance with San Joaquin county Ordinances.state laws,and <br /> ruses and regulations of the San Joaquin County <br /> Home owner or licensed egant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not i <br /> employ any person in such manna as to become subject t workman's compensation laws of California."Contractor's hiring or sub-conttaoting signature �,, <br /> _ c the loaowing:"I c that in the pe orfrre the k toe which this permit is issued,I shall employ perecns subiect to workman's compensa- I <br /> 1 On lawn O NOr .` 7 <br /> The applieanl u all i all requ spa ti ns. o to dra reg On ever <br /> Title• '�s'�G �j Oata`� <br /> .)R ARTMENT USE ONLY <br /> Application Accepted by _ Pate - Ldp_ Area�[� i. <br /> Pit or Grout Inspection by Data Fin sf Inspection <br /> Add6onol Commenu: <br /> II <br /> Applicant Retarn at1 copies to: San Joaquin Coun'.y Public Nealth Services <br /> Environmental Flealth Permit/Servleen <br /> 445 N San Joaquin, P o Boa 2009, Srkn, CA 95201 �7 <br /> t <br /> FEE AMOUR'DUE AMOUHT REMttt ED CASH RECENED BY OATS ETT-1 <br /> o. <br /> INFO ` <br /> . EM ll.tr lRLlr.treat r� . <br /> ' IH t1�fi .��� <br /> r <br /> I� <br /> 7 <br />