Laserfiche WebLink
SALT JOA . <br /> t70EIZTY'PUBLIC .gEAI,TH.;SIdtCV lt�il , . � , <br /> $� 1R [RNTAL gEALTH-°D'V'SIOI+j <br /> AVE. : (209)46$-« r0 <br /> 1601 T.. _ K PHONE <br /> CA 95201 <br /> P O Box: 2009, S`T0C N. <br /> RBS 1 FR T <br /> (Complete in Triplicate) <br /> t to conatruet and/or install the work herein described. <br /> of Sens <br /> :Application is hereby etede to San Jo-quip County Zor a Pew end the Rules and Regula <br /> application is � COW s rriaeta� Ban Joaquin County Qrdiaance No. <br /> 549 and 2862 fl O[cl`� <br /> Joaquin County pu C 1`� D Lot Siae/Acreage - <br /> p So 1 iZ o An r t� itr f�S F� <br /> J Address r�`ti Phone^' ` r <br /> \ Address 3 _ <br /> ---- <br /> License NO. Phone <br /> Address DESTRUCTION ❑ Out of Service Well ❑ <br /> Cenlractor WELL REPLACEMENT"U )tonitoring.xe 0 <br /> NF-W WELL 0 -OTHER.❑ .. <br /> TYPE OF WELLIPUMP_ --SYSTENt REPAIR 'r -._ PROP, LINE <br /> - .. -pUNip-1NSTALiATiON-17...-^�"'-•--•----- DISPOSAL fLO. " <br /> SESNER LINES ------- OTHER WELL, -.--- PITS/SUMPS �. <br /> DISTANCE TO NEARI~STi SEPTIC TANK �--�- AGRICULTURE WELL <br /> FOUNDATION_.�.--- <br /> `.... OF WELL PROBE ` CONSTRlfC7lON SPt CIfICATIONS �.of Well Casing <br /> "INTENDED USE ©liAanteca pia-of Well Excavation <br /> 0 Open Bottom specifications <br /> I:1 Industrial Type of <br /> aCasing <br /> Ll Dnesteciprivate ❑ Gravel Pack ❑Tracy Type of Grou <br /> Depth of Grout Seal <br /> I'1 Public # n other h n Delta Su:tace Seel Installed by <br /> _�Approx. OBPt 0 <br /> �trripation H.P. State Werk Done <br /> Repair Werk Done 0 Type of Punk ------ Sealing Material E � �+ <br /> --- <br /> CivhT� <br /> Wad Destruction ❑ Diameter <br /> Wed Filler itaterial i Dept <br /> Depth. mined if public sewer is <br /> available within Z00 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 RfpAIR1ADDI fiON i 1 OE53RUCTlON I 1 tNo septic system per <br /> Installation will rva: Residence-- Commercial Other- __- <br /> k Number of rnring units: Number of bedrooms Water table depth <br /> Character M oil to a depth of 3 lost: . Carnpartrmnts" <br /> Capacity----- �" of Dispose <br /> SEPTIC TANK" p 'Type/Mfg dved <br /> Met - <br /> - Line��---- <br /> PKG.TREATMENT PLT.❑ foundation�-- Pf ` <br /> = D•,stanca to nealesr` Well" <br /> Total length/size <br /> LEACHING UNE Ll No.ftp Length of lines Property Lino ��--- <br /> FILTER SED 0 Distance <br /> to nearest: Wed---�-- Foundation��--- <br /> Number i <br /> SEEPAGE PITS I I Depth property Lina -� <br /> SUMPS <br /> Li p"rstanoe to nearest: Wed�� Foundation -� <br /> DISPOSAL PONDS- ❑ 1 in accordance with San Joaquin county ordinances,stata'laws, and <br /> �k anon and that ilia work will be done <br /> 1 hereby certify that I have prepared this _ lar whicf+3his permit is'issued,1 snail not <br /> tions of the San Joaqut' that in the performance of the work $ nature <br /> rules and raging tt►a fodowin$:'� Y t�laws of California.•Cantractoda hiring or sub-contracting sift <br /> Horne owner or �nrs signature certifies <br /> efnploy any person fit such manner as to became subject to workmans compensation workman s cortepensa <br /> orrnensa of tha work for which flus pelt is issued,l shed amploY. reOs!s'�bject to <br /> aer[ifies <br /> the fodownnp:"I cerdty that in the pest <br /> :.tion laws of CaFefornie" - F ns. Complete drawing on reverse side. f t <br /> Thea t Must for so reg Date: <br /> Tide: <br /> r Signed <br /> ' 1 FCR DEP- ENT USE ONLY <br /> Date Area <br /> Application Aceept0d by <br /> �.-�-- final Inspection <br /> Date b <br /> PTR or Groat Inspection by <br /> Additional Comments: <br /> ices to: Baa Joaquta Courtly Public health c <br /> Applicant -^ $et= all cop S vie-a.-savironsentel•BeLIU.Permit, CA 9$201 <br /> 1601 >;. gar,e3tna Ave., P 0 Box 2009. Stockton <br /> CK DATE PEttMl7 ND- <br /> CASH itecElVED BY <br /> FEE AMOUNT DUE AMOUNT NEM177ED l <br /> INFO <br /> Ll <br /> Efit3Z4(REV.1 as; �'+J <br /> tit tae •r` _ __ <br />