|
r
<br /> APPLICATION
<br /> " 4
<br /> SAN JQAQUxN COUNTY PiIALIC HEALTH SERVICES
<br /> ENVIRONMENITAL HEALTH DIVISION
<br /> t, 445 N SAN JOAQUIN, PHONES (209)488-5420
<br /> P O BOX 2009, STOCKTON, CA 95201
<br /> s i;s PERMIT EXPIRES 1 YEAR_F'ROM DATE ISSUED
<br /> $ (Complete in Triplicate)
<br /> +11111 f �.
<br /> Appllcstion in hereby made to San Joaquin County for a pe�c:t to construct nnd;or install the vork herelt: described. This
<br /> application is made in cot'rpliance Pith Sen Joaquin County Ordlnance No..549 and 1862 and the Rules and RegvUtions of Sao
<br /> K i a y r Joaquin County Public Health Services.
<br /> Job Ade. ss _ -91301A.r IAILDRETR LAI city_ Lot Site/Acreage
<br /> 4 q Owner's Name _ Acfdr�eyss�p� Phone �� 1
<br /> (}���
<br /> l 1 A 'j �' Cantratiol�i+ C1C Pfiff_ hdC+ss -Ss License NiI. . 13 PhonejS 1 7— '
<br /> J - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC`_,MENT Fl DESTRUCTION 0 Out of Service ket2
<br /> PUMP INSTALLATION SYSTEM., REPAIR Cl OTHER ❑ I/onitoring Nell LJ i
<br /> df 'ic f w
<br /> s DISTANCE TO NEAREST: SEPTIC TANK SENrER LINES -._ DISPOSAL FLO. PROP. LINE.
<br /> FOUNDATION AGRICULTURE WELL __ ETHER WELL PI'S/SUMPS
<br /> INTENDED USE TYPE Or WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> } f
<br /> ❑,Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia.of well Gating s#
<br /> � 7A 3�DoalcstitlPrivata Ll Gravel Pack ❑ Teary Type of Cas+ng Spetifiea:icrta
<br /> " „
<br /> I'I Public I:1 Other f-1Oelra Depth o!Grout Seal Type nl Groul��_
<br /> -I I Irrigation Apluox. Dopth I I Easlerr. Surface Seat Installed by
<br /> i -
<br /> x if s° ,;' Repair Work Done 0 Typs of Pump _��� H.P. State Work Done
<br /> o z F ty�r Well Destruction ❑ Wolf Diameiar Sealing terMs ia1 i Depth 92 1AMLLrT.It(
<br /> Fs � r Depth Filler FSaterial i Depth
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION! I RSPAH'IAOOITION i l DL"S7Rl1CTION I i [No segue system permitted if uts9is newer is +� r,t
<br /> f•. p
<br /> available within 2W feet.)
<br /> ga r x',.r r -'�4rs,,,,`".;-1 insf:!4[ion w;TI serve: Residence Commercial__ Olher
<br /> Sr 4 1 G 7f5 '.r
<br /> �A
<br /> s y , w Number of liv»r.,units:- Number of bedrooms 4
<br /> Charactor of wi;to a dipih of 3 foot: Waesr table depth "
<br /> -,4
<br /> r,, ?-,r f SEPTIC TANK f] Type/Eafq Capacity -- No.Compartments
<br /> PKG:TREATMENT PLT.0 Method at Disposet'' ~d�
<br /> ,�'• cos f � <�,,,.n, q, Distance r,[o neete� '.belt Pzundetion � Property line �
<br /> LEACHING LINE 0 No,8 Length of lines Tats!length/eine k'" �'•;
<br /> f Y & r FILTER RED C] Distance to nearest: Well Foundal'con _ Property Llne 4d
<br /> f -
<br /> �,
<br /> SEEPAGE PITS It Depth _,Sire-. Number F,
<br /> n SUMPS, L' nearest:I Distance to Well Foundation Orono. Lite
<br /> k rk
<br /> DISPOSAL PONDS CJ
<br /> I hereby cenity that i have preperod this application anti that the work will be done in Accordance with San Joaquin county ofdinances,nate taws 'seid
<br /> rules and feAulnions of the San Joaquin County
<br /> Home owner or licensed agent's signature certifies the roltowtng:"t certify that in the performance of the work for which this permit 0 issued,1 shall n,l
<br /> 'employ any person in such manner as to become subject to workmen's compensation laws of California."Conlractor's hiring-3r sub-contracting fignatursY
<br /> a, ti'i rFc t�5 canifios the lollowing:"I certify that in the perforrhsncs of the work for which this permit is issued,1&hall employ persons subject to wnrkrnan a earnpsnsa•
<br /> "$ tion laws of Callfornia:" Z
<br /> �r1 ! The applicant must seq for all required inspeclio . Comptals drawing on reverse si
<br /> t F ?
<br /> Dots:. �G " [ Z
<br /> r n A r'•�a +;; { S)gned
<br /> Title:
<br /> r,
<br /> FR DEPARTMENT USE ONLY y X1
<br /> k d" ep i 3 a n Appllatlon Accepted by �r_ -- s.aCil 'ems" Date Arse ff
<br /> Pit or Grout fnslyactbn by Date Final tnrpe0tlan by
<br /> 1 •.^"he '',6�q, 1' � //" d
<br /> Additlonal Comments:
<br /> Applicant - Return all cuptes to: San Joaquin County Publir- Health Services - �• 'i 9 '
<br /> 6nvironrwntal Health Pormit/Servicaa ° M
<br /> e4g N Ran .loa4u in, P tl Durr SOVB, 9Ckn, CA 88201 4
<br /> y t�
<br /> fi
<br /> tA
<br /> A4 �� S _ FEE AM04NT DIA AMpUNr RFMM EU RECEIVED BY VATS PERMIll'No.
<br /> INFO CASN
<br /> 177i
<br /> 71.7&
<br /> ' y�,"k't�.N-.�„ .-.,:.«.,. ,...� ,----......_....-..�.. -- -•• --..._...�..,. w, _.-...._......w,-.�r;,r,'a .� x_:..<r.a-,.,.:.r. .,-,...»,..._,,....,......,..�._,......,_.---- :•au�,•r
<br /> 1 r
<br />
|