Laserfiche WebLink
APPLICATfON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIL <br /> ENV I RONkENTAL HKALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468•-3420 <br /> C P 0 BOX 2009, SPOCbTOH, CA 95201 <br /> PENIT EZPIRE4 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby saAe.to San J0a4ulb Cotmty for a Peralt to construct and/or install tbs vork bere,n described. This <br /> " application is wade in cavliance vitt Baa Joaquin County DrdirrLes Ho. 5A9 And 1862 and the rules said RegulAtldas of Suss f <br /> Jcquin County Public Health Services. /n <br /> y Job Addms 'civ Co [�A1 S _ Cmv O/l� Lot Bite/Aeriiw <br /> Owtwr's Nares Address Oe! Phone i <br /> / A&;ess ? o Z o /y/lc%_Licensv 140-a /��P PhOnt <br /> Contacts a <br /> TYPE Of WLLI/PUMP: NEW WELL O WELL REPLACEMENT it DESTRUCTION ❑Out of 'hrvito Moll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ tboittriaA Pall <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_— PROP.UNE <br /> FOUNDATION: AGRICULTURE WELL OTHER WELL MTSISUI IPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 lrk u:Trnel U Open Bottom O Manteca D.G.of Wad E■crva:ion _ Dia.o/Wes Caeirtp j <br /> rl Domestic/Povete ❑Grv,4 Pack ❑Tracy Type of Casing_. Spec+f st'o^a <br /> 1'1 FNib6c n Otho rl Defta Depth of Grow Seal Type d Grout f lit <br /> I I Migeton _Appro..Depth I I Eastern Surface SNI InstaW by 1 <br /> Repair Work Dore U Type of Pump H.P. State Work Done =— 1 <br /> Was Desvuction O Wad Dierneter Sealing Material L Depth 1 <br /> Dtroth _ filler Material 4 Depth 0 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR nA DDITION x DESTRUCTION I I IN.,sepnc eYsanm pern~a prbbc sewn ii <br /> evadable w Q%'v 20D 1W.I <br /> A <br /> kutaxation VA soya:..Raeidw4a-'k"Com+w+c.0_ Other <br /> fr'urn+ber of GvinO units: Nurt+Mr of—Aroonr <br /> Chwwuw of sa to a depth—T feet: ,Q B ww«uh,r daps <br /> SEPTIC TANK O Type/M1g Capacity <br /> No.cornpartrttants <br /> PKG.TREATMENT PLT.❑ Method o1 04posM <br /> Distance to nearest: Welt Foundetio•n Property L4e <br /> LEACHtNG LINE ❑ .No.i Length of Fes y0 Total length/site <br /> FILTER BED 7 Distance to nearest: WON Foundation Properly Lime <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS IV Distance to nares: Was Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cendY that I he"M!>anC this opokst on and mat the work wo tie done on accordan."with San Joaquin COU MY OttfiferKM,ftNa Nes,ale <br /> rtots/and re"tK.ns of the San Joapuil County <br /> Home owner or Licensed apenYs ronature oerlrlOne <br /> the foaowrng:"I certify that n the wormer nce of the work for which Otis petmn Is issued.I shad not <br /> ernpbY any person in such mr»et as:o become subtect no workmen's CompereatiOn taws of C.aaforfra."ContracWs hiring or sub-contracdng rprtatiw <br /> cert:ioa the foaowmg:"I ctrofy that in ue partotrw+cs of the work for which IMO permh r issued,i shall employ persons s+Opct b workman's CORVOrtse- <br /> bGn WM of GeirtO""." <br /> The applicant must cam for M re",inspections.Compiets drwi ng on reverse side. /� q <br /> SgMd X HL' Tide:__�We t Sit s Dap: -.F- <br /> [KT <br /> /!NT USE ONLY ; <br /> ApWATW.Arxepted by <br /> .rL1 -r eZ. <br /> ►M or Crout Inspection W Data FirW Inspection M7— <br /> Additional Conrtenta: <br /> Applicact - Return all copies tn! su Joaquin County Public Health services <br /> [bvtrooaieu!sl Health Psrsdt/Bervlcee <br /> 4<S H Ban Joaquin, P O Bua 2000. Btks, CA 93401 <br /> 0 AkIDUNT DL'S AMOU14T RMIT <br /> ETFD CASH CK 0 PICINED BY DAT[Pi <br /> M_IIAtls NO. <br /> wtattgay.,,.v a/ I / n� .Z L Z-031Y <br /> IN WHO <br /> Y <br />