Laserfiche WebLink
f .�? y'-r" ��L.'r <br /> 4 "^CbY'Iti £�e'arr'�'r, �r <br /> 1 - �• - � let__, t.' l q. �z�� G�?� 12�r <br /> Y � <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROMMTAL HEALTH DIVISION <br /> s 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> y I13SUED <br /> r (Complete in Triplicate) — <br /> ( Appllaatlon is hereby arde•to Sia Joaquin County ror a permit to construct and/or install the vork herein described. This -_ <br /> application is rade in compliance vlth Ban Joaquin County Ordinance No. 549 and 1862 and the Rules aad Aasulations of $art <br /> Joaquin County Public Health $erviecs. <br /> Joh AddnuLot Stie <br /> City A{n���ereag <br /> Owner's Name Address ^�PfSpne S�S <br /> Contracts Addiess License No. Pngne � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL 99PLACEMENTOrl DE CTION Ll Out or service well 0 <br /> PUMP INSTALLAT:00 ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring hell ❑ <br /> + DISTANCE TO NEAREST: C TANK SEWER LINES OSAL FLD. PROP. LINE <br /> n FOUNDA, AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPrr OF WELL OBLEMARF-A CONST ION SPECIFICATIONS <br /> 11 industrial 0 Open Bottom ❑ Ma Dia Well Excavation Dia,of Well Casing <br /> 0 00masticlPrivate 0 Gravel Pack L7 Tracy a of Casing- Specifications <br /> Il Public. n OIhLr 17 Delta Depth c Seal Type of Grout <br /> I I litigation Appose,Depth I I East Surface Sea Installed by <br /> R� Work Done U Type ype of PurttF H.P, State Work Dona <br /> -' WW DNUuction - ❑ .Won Diameter':_ Scaling Material Depth: <br /> ,, .f .• Depth - Filler Material i Depth - <br /> 1f TYPE OF SEPTIC WORK: NEW INSTALLAT.ON REPAIRIADOITION I i DESTRUCTION IN septic system permitted If public sewer is - <br /> '.; ? available thin 200 taet.I- <br /> Installation win sarva:'-Residents X :COmma:c$al_` Other J3erJ es7aX •' '{tS ..��r rues "-first - - <br /> Number of living units: Z- Number of room - 'fefia� <br /> a Character of sI to a depth of 3 feet: <br /> Water ladle depth <br /> SEPTIC TANK 4 T DO ` <br /> i. ypelMlg Capacity No.Compartments <br /> PKG.TREATMENT PLT.0 , Method of�Disposal <br /> e.� Distance to nearest: Well X00 Foundetan Z Property One . <br /> LEACHING LINE Cl No.6 Length of line. ,ata$lengthleite CD <br /> r FILTER BED "l7 ''Distance to nearest: <br /> . Foundation Property Line <br /> ' :,'-.;:y;:.,. .,.,-'•; SEEPAGE PITS I I Depth Sue Number _ <br /> { SUMPS LI Distance to nearest: Well Foundalion Property Line <br /> ._ DISPOSAL PONDS O <br /> 1 here <br /> ,••... ...,; £ blr certify that 1 have prepared this aPW$C+tan and that the work will W done in accordance with San Joaquin county ordinances,nate laws,a _ <br /> t rules and regulations of the San Joaquin County - - - <br /> - Moms owner or licensed agent's 'e <br /> ape signature CMifws the lollrtwing:"l certify that in the performance of the work for which this permit is Bawd,I shall not <br /> i employ any parson in such rrtanter as to become subject to workman's compensation laws of California."Contrecto:s hiring or sub-contracting signature <br /> C*fbfia the following:"I cenify that in the pertormence of the work for which this permit is issued,I shall employ persons subject to workman's conwnn-� <br /> tion Isms of Calilorrtis." <br /> The applicar9se tall for eer fired inspe.cWtis.Complete drawing an r side. - - <br /> - i ,signed x .d¢n1 Title• .�'�/e�='�ya,4���� Dat.: �[��� ;..:_ <br /> ° OR DEPARTMENT USE ONLY l <br /> - ApplicatloA ACuptad by Dats Area +' <br /> ' Pit at Grout I y ' <br /> I nepsction b Date .FK­. <br /> pection by 'Dau ld � 9 <br /> i. Add"dlonal Convrrnts: ._S_Ssi� •i a•. .L r r�a a a _ <br /> Applicant - Return ail copies to. San Joaquin County Publle NeaIth Services <br /> Environmental Health Permit/Services - <br /> 445 N San Joaquin, P.0 Box 2009, Stkn, CA DS201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED- twSH CitRECEIVED BY GATE PEAMITNO. <br /> � / a <br /> .INt>~zrtaav"ii.v <br /> IN nese .0 <br /> I. <br /> 7. <br />