Laserfiche WebLink
.,., <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)968-3420 <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> PEMIT EXPIRLS I YEAR FROM D TE ISSU,O <br /> (Complete in Tripiicate) <br /> Application is hereby made.to Set Joaquin County for a permit to construct and/or install the work herein deecrlbed. Thla <br /> application is made in ccdpllance with San Joaquin County ordinance no. 5,,9 and 1862 and the Pule@ end Ae/ulations of Sen <br /> Josquln County Public Health Services. <br /> 4 <br /> R Jou Address 2� P, ix y L l Lot S1te/Acrengc <br /> Owner's N@me L��f7IV - '/7/1Y Address 2yg.21. r Phone. _ ^� <br /> Cpnira0�lr ;/4' a Addie - -��± Y' 1, _ er," Hpr-1.=�=1 Phone <br /> TYPE CIF VVEL'rPLM. NEW WELL C] WELL REPLACEMENT F! DESTRUCTION C W, or Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM PEPAfR � OTHER ❑ monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES — DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION AGRICULTURE V: LL OTHER WELL____._____ PITS/SUMPS _ <br /> INTENC10 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (7 InJuslna; ❑Dpan Bottom ❑ Alanteca Dia. of Well Excavation _ Dia. of WOR Casing <br /> ('1 DomislicrPnvite CI Gravel P.sck CI Tracy Type of Casing_ __ Speuficatiom <br /> I': Puhbc 11 Other n Celyd Depth of Grout Seal Type of Grout <br /> I I Inlgetion —_ Approl, Oeplh I I Ebslern Surface Sedl InstaUnd by <br /> Repair Wary Done 0 Type of Pump _ H.P. State Work Done� V' <br /> WeII Deseructian O Weil Diameter Sealing ltattrial i Depth _ - <br /> Depth Fl ler Na Lerlal i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAI-I-ATION I I REPAUFIADFM67x DESTRUCTION I f INo septic system parmittad if public sewer is 1 " <br /> available within 20o feet 1 <br /> Installation wilt serve: Residence X Commercial_ Othe1 <br /> Number of Wing uods:j—_,., Nvr.rber of bedrooms <br /> Character of soli io a dopih of 3 feel: `�rq4IQV Water table depth <br /> SEPTIC TANK 0 Typa/Mfg Capacity­— No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation_ Properly Line <br /> LEACHING LINE Ito, 6 Lengv-,of lines 1-L' 1 C—� Total 16ngth/size <br /> - - ' FILTER BED n Distance to nna,asli WeII Property Foundation��_ Pro rt Line " <br /> i <br /> SEfPAG1;PITS �'K Depth _,� Size <br /> SUMIPS LI Dlslsnca to rlamest: Welt I JTZ Foundation !FZ2 Property Line •2/— <br /> DISPOSAL PONDS ❑ <br /> I heeteby certify that I have prepared this cppllcation and that the work w;h be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules end mgufatlons of the San Joaquin County <br /> j: Ht:me owner or licensed agant's s;Qnalure certifies the following: "I cenify that in the performance of the work for which this permit is issued,I shalt nor <br /> entploy any parson in such rnan4ef as to become aubfect to workman's compensation laws of California."Contractor's hiring at subcontracting s4natunr <br /> certifies this folfowing:"I certify Char:n the perlormance of the work lot which this permit is issued,I shall employ persona subject 10 workman's comyensa. <br /> tion laws of California-" <br /> 'v. The applicant ae for ill rrgwr ed." sFec[ - Co pi drawing on reveres lido. <br /> 1 <br /> Signed ! Title:_ a r — Datr. <br /> ;Y ✓ <br /> > (�r1OR DEPARTMENT USE ONLY <br /> a�'s.�1.1 ___f_ <br /> Applicatlon Accepts:l by - '�! � _ Dole - Area <br /> Grout Inspection by i�rg Final Inepec ion by ` Das "�" <br /> ACditkin+!Comments: <br /> - App-orant - !tetutn all cople+ to: San Joaquin County Public Ilealth Scrvi,tas <br /> -_ Environmental Health Permit/Servicer? <br /> 445 H San Joaquin, P 0 Box 2009, SLka, CA 95201 <br /> - ! FEE AW.OUNT OtlE AMOUNT RFMITTEO A,14 RELEfVEO 9Y DATE PERMIT Na. <br /> iNFO <br /> 1H 11.14 Is EV.Ia 11 y �L�i.� � l ! r�C1 1 i_;7 • 1� 2 / �3 �� �"f . <br /> L4 11,10 <br />