Laserfiche WebLink
r `./ <br /> APPLICATION `/ <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 145 N SAN JOAQUIN, PHONE (200)458-3420 Pyy� <br /> P O BOX 2009, STOCKTON. CA 95201 <br /> PERMIT ^RPIRES 1 VAAR FNOM DA^aE ISSU4'x'D <br /> ` (Complete in Triplicate) <br /> Applicatlon Is hereby nese to Sut::qudv Ccanty for a permit to construct and/or Smtall the >,.rk herein deteribed. This <br /> aPYlltaticv 1. rade in compliance vrth San lwgvio County Ordinance No. 549 AM 1962 and the Aisles "pi .^'RU=Atipva of San <br /> JoWula County Public Health Services. [.�/ <br /> Y� ir'^S V •J �d•�/{ _ City Shot 51se/Acrea1gT <br /> JW n <br /> Add ,s � ! <br /> w"'l/i" M UA�1 � %,a 9/2 S l_AC,2 phone 9r1f 900 <br /> Owmi a iienr <br /> /12 7 7 <br /> � 3Pnone <br /> C9r•3CIX �u�/J AddressL LicenseNo. i <br /> _ <br /> TYPE OF WELL/PU--_ NEW NELL C WELL REPLACEMENT fl DESTRUCTION Out of�Stor1o{Well Cl <br /> PUMP INSTALLAT!ON 0 SYSTEM REPAIR 0 OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES <br /> DISPOSAL FLD.__ PROP.LINE <br /> '— FOUNDATION _AGRICJLTURE WELL _— OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL Pn09LEM AREA CBNSTRUCTION SPECIFICATIONS <br /> _ - Du.91 WeM Calling <br /> -- Il hduatrnl ❑Opan So•tom ❑Manua Dia. of Well Eacsvalion <br /> T f Cair i—j—' <br /> SPeclDcat'ons <br /> (i Oomesue/private O G,&"Pick L] Tracy Type om'--- Type <br /> of G,wt. —� <br /> I i Fublie I1 Other fl Dells Japtn of Grou[Seal <br /> urr0a[rm —_ApWo--Depth I I Easum Scrucs Saul tnau'!ar!M <br /> H p __ Slate Work Dom_ <br /> Wall <br /> Work Oon. ❑ o1 Pump __.�- sealiht Materiel L Depth <br /> Wall Dastruttbn Wall wall me <br /> Diater / filler Material A Depth <br /> k s Depth lb <br /> i•[pE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I ;�p rle,�!M�2200/pt-I '!p"dk rower <br /> Iiilll.tonatio I, Residence_ Comrmrial_ Othm ' <br /> Number N <br /> of Yvim uniu: umber of bedrooms / < <br /> ` Vi table 61011, J <br /> CharacterA K aoE to s d0 of]1 Cf No.Compu[rmnu <br /> SEPTIC TANK O Type/Mfg Method of Disposal <br /> PXG.TREATMENT PIT.❑ <br /> Distance to nesresY ell perty Lim <br /> if. LEACHING <br /> Mngth/sits --{ <br /> LEACHING LINE ❑ No.byrsplh of linea - <br /> - FILTER RED C.'Manta to."rest: WNI Foundstuln _ Plops Llm <br /> / \ <br /> '� 1I Depth Sin__ Number <br /> SEEPAGE TS' Foundwun Property Lim <br /> SUM LI Distance to mares: Well <br /> _ 0 OSAL PO U am in occoirownce sith San jo,,uirg coomy o,dbass,and <br /> I Iuraby certify that I hew W.,ned this application and nat)ha w rk II b d <br /> ruNa and rsoul.,on,of lm San Joaquin County nand a isauad.I NSE not <br /> hasHome pwmr or licensed agent's signature penifie.the Iotlaw+n0:"1 carott'that m tM pa'lormance of the rood fd whKh that W signature <br /> <eH r[m o owiniri g,'Icn iHMegg-10 t in[he peAor tura of wbPcttoche work for wh ch h i parmllNa unad.lf still empbY persona subject o worYtman'�cornpanM <br /> don buns os Oell[5t C11' drswir. <br /> The IPWictnt ri rr all, ! s/'�`Js.Comps g p^re �q.,•{'��< i� —27/—�Z <br /> age �[./t-1' / VC �"4nis: �"'- Dau: <br /> Sipned <br /> OR DEPARTMFYT USE ONLY <br /> Dau�� Ana t <br /> Appikelan ACceg ad by �l <br /> 1'Y insl ImpKtion by .� <br /> Data <br /> was Pit o(G o• t b `at by / Data �G , vI <br /> - Addilip"rtom nu: r` Servicer <br /> L Appif<an: - Return ell copies to: San <br /> Snv[ronment lotical tb P.r.it/S."icti;.. <br /> 445 N Sen JOvatln, P O Dez 2009, Stkn, CA 85201 <br /> K Zfif-:H57 <br /> VI FFRMII'ND. <br /> FEE AN.DUNT DUE AMCUNT flFMtTlEO CASHNFO �� �.k6 <br /> .ML <br /> tN laic <br /> t <br /> L <br />