Laserfiche WebLink
APFL[CATTON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVII Ev# r�tar� <br /> ENVIRONMENTAL HEALTH DIVISION Dl? <br /> 445 N SAN JOAQUIN,PHONE 209 469-3420 <br /> P O BOX 388, STOCKTON,CA 95201-0388 <br /> PORNIT EXPIRES -1 MR FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby m e&to San losquin County for a permit to ronstmet and/or install the wort herein descrbed.This appliauioe Is trade in axnplionc a with Safi <br /> -10aquin County Development Title Section 9__-11/I10.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services.. <br /> Job Address ! �Y n�G �:[ city I�G✓L�t Let S1ze/Acrrge - 1� <br /> Owner's Norma � CS i-t-7 Address <br /> - PhoM <br /> Contractor t '��Address 415 License N0. ulna <br /> TYPE OF WELLIPUMP: NFW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION 0 Out of Service Nall <br /> PUMP INSTALLATION 0 SYSTEM REPAIR.0 OTHER D Monitoring ve.11 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL+LD. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PS _. <br /> INTENDED USE TYPE OF WELL "OBLEM AREA CONSTRUCTION SPECIFICATIONS7" <br /> ❑industrial D Open Bottom ❑Manteca Dia. of Well Excavation Z <br /> � <br /> * DommiciPrivsts 0 Gravel Pads ❑ Trs^.y Type of Casmq_ <br /> f"I Ptotic ' 1 <br /> F1 Other fl Delta Depth of Gout Seal "TU <br /> I I Irriontion Appian. Depth I 1 Eastern <br /> Surface Soul Instated by N '�cr <br /> Repair work Done L3 Typo of Pump H.P. State Work Done <br /> wet Destruction ❑ Wall Disaster tiaallag Htsteriai i Depth doh, <br /> Depth_ Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLAT+ON t I REPAIRrADDITiON DESTRUCTION I i INo Septic syatam permitted if <br /> Dottie sswus <br /> avagable within 200 tact.) <br /> Ittatataiipm will carve: Residence L�,.+CorrrmereiN Ott»r <br /> Number of cluing units:�_ Number of bedroornt� <br /> Character of sol to a depth of 3 feat: .' _1�h t, 4Y1 W&W tabic depth <br /> SEPTIC TANK O TYtne/Mfg Capachy No.Compaetmsito- <br /> PKG. TREATMENT PLT;LI Method of Disposal <br /> Distance to nearest: Wee_�_ Foundation Property Line <br /> LEACHING LINE 0.1 No. d Length of lines _ a Total Iangth/sins <br /> FILTER BED 0 Distance to nearest: Well rJ'IS Ftw <br /> nunaan�� t Proper y tart! <br /> SEEPAGE PITS I I Depth _� Sin Number_ <br /> SUMPS 1U''�ObgrH4a Q:t~a►weat: wall W O Foundation PrOpwty Lina �.L1 <br /> DISPOSAL PONDS ❑ <br /> 1 hereby Certify that I have prepared this application and that tate work will be done in accordance with <br /> rulSan.HoagtHn county ordittaRCq,sura laws, and <br /> es and moulalions of the San Joaquin Count? <br /> 1'br^a owner or kw—d aparn's spnature=Mfws the following: "I certify that in tow parformance of the.cork for which @ti;permit is itMued, I shall not <br /> empRry any person in such.nionew sa to become subject to workman's compensation laws of California,"contractors,hiring or stlb•conttraetinq signature <br /> Certifies the follovwnp:"I cantly that in the performsrwo of the work for which this permit is issued,I shat employ,paaMA subject to*Wknrn't<cor"C"sa <br /> tion laws of California.,, <br /> The applicant must call for aA ��/gju�irfd�J�nttprgipeilk Cmrtpltlta drawing on reverse side. <br /> SiOred X__tom+ Title:_ 111N-0,Or- Dstf: _ L/ _ <br /> FOR DEPARTMENT USE ONLY M <br /> Application AacapiMM by C Data <br /> wit or l3wut ltikgetion by Final Inspection 00 <br /> 1WdidofW 0WR~q: <br /> Applicant - Return all copies to: San Joaquin County Public Haft Services <br /> Envizonnteotat Health PertmitfServias <br /> 445 N.San Joaquin.P.O.Boz 3888 Stockton.CA 95201-0388 <br /> r FEE <br /> r INFO 4 ff E �l►tOUNT REAiITTED RECEiI/)q t1Y DATE NERWT'No. <br /> iMf1lYgaV.+�se � � � � a <br /> f tiCT 4L <br />