Laserfiche WebLink
TY-PUBLIC HEALTH SERVICES - <br /> APDLICATIp�U1dj ��;,HMTHDIVISION <br /> SAN JOAQUIN COUNTY PUBLI � IT <br /> ENVIRONMENTAL HEAL <br /> 445 N SAN JpUIN, PHONE (209)46$-3420 <br /> A' ,. <, � p O BOX 2009, STOCKTON, CA 95201 i <br /> t <br /> pEgB T EXPIRES 1 YEAR FR DTE S <br /> {Complete in Triplicate} <br /> made to San toaquin County for a permit to construct and/or install the Ruleworks <br /> herein Regdesulations <br /> of Sans <br /> Application le hereby O <br /> application 1s made in cae�liaace,with San Joaquin County Ordinance No. 549 and 1862 and the Rules en�� �� <br /> Joaquin County Public Health Services. Lot size/Acreage <br /> r <br /> Cit_ LL _ �7 <br /> Job Address . '-. ' h <br /> s ' i Phone v <br /> Address <br /> Owner's Name r <br /> 1-n✓ <br /> License No. Phone <br /> ddressDESTRUCTION Out of Service Well, L1 <br /> Contractor WELL REPLACEMENT . monitoring Well C)NEW WEL`L`S OTHER C3TYPE OF WELLIPUMP: SYSTEM REPAIR 0 t <br /> ` PUMP INSTALLATION ❑ `- DISPOSAL FLd.r.- PROP. LINE _ <br /> DISTANCE TO NEAREST:.fSEPTIC TANK .�.-.-••— SE•-ER,,LIN S -�� OTHER WELL PITS/SUMPS <br /> OUNDATION-� AGRICULTURE 17VEkL - <br /> FC� <br /> TYPE OF WELL PROBLEM M AREA CONSTRUCjION SPECIFICATIONS Dia of Well Casing <br /> �. INTENDED USE pia. of WeH Excavation , r ri <br /> Cl Industrial ❑ Open Bottom ❑ Manteta ;..a` Specifications <br /> • Type of Casing_ E <br /> ❑ Tracy '.r Type of Grout <br /> fel Domestic/PiivAte Vii-Grewal Pack n Delta depth of Grout Seal <br /> 1'1 Puhe <br /> blic Cl Otr z <br /> t ok. Depth I I Eastern Sulfate Seal installed <br /> mss'\l r � State Work Dons - <br /> I I Irrigation �. . H.P. <br /> Repair Work Done U Type of Pump - �ITIOJ� <br /> ial th t I <br /> Sealin <br /> I Well Destruction ❑ Well Diameter --- th ' fi <br /> Filler al <br /> Depth rmilUe If ptirbc-seis <br /> TYPE OF SEPTIC WORK�RtE '� DDDESTNIICTION l I Aysilabla�w lin 200 feet•I <br /> . I <br /> Instanstion will serve:! Residence L--Commercial— Other�� <br /> Nurn'ber Of bedrooms --- t V <br /> Number of living unite: _ _£Water table depth <br /> I Character of SON to aj,Wth of 3 fest <br /> -{� Capacity -No. Compartments., <br /> SEPTIC TANK. ❑ Type/M!'9" Method of Di <br /> PKG. TREATMENT PLT:.❑ �YWell t <br /> f �� Foundation�,`PropertY Line <br /> Distance{{to nearest: <br /> =Distan" <br /> Total lengthlsi2e �- - '•' � <br /> LEACHING LINE gth of lines } //� <br /> (�. Foundation 2�-- Pr C Line-� .6"'-- f�" <br /> FILTER BED Dp nearest: Well s. <br /> F <br /> t <br /> { { Depth$' D Number ` <br /> SEEPAGE PITS r ' rd a S <br /> - pr ane J <br /> SUMPS Distance to nearest: Well Foundat{gn - ri <br /> ! DISPOSAL PONDS © SLIMp 45 Ir rf d a6�>K. nd , <br /> { hereby certify that I have prepared ,his application and that the wor 11 b done in accordance with San Joaquin county ordinances., state la+lns, <br /> - .�- =' - - all net <br /> rules and regulations o1 the San Joaquin County - --,_k- i <br /> Home owner or licensed agent's signature-cenifiemite-the -"I-csrtify`tfrat nature <br /> employ any person in such manner ai to become subject to workman's compehsativn". �OWAWN&n•s componss- <br /> Certifies the following: "I certify that in the performance of the work for whit pe y� /► MIT <br /> tion laws of California." Sl C�I�L P��MIT <br /> The applicant must call for all uirsd4nspectio s. Complete drawing o, averse side. <br /> `� <br /> Title <br /> T - Date: { <br /> Signed <br /> -FOR DEPARTMENT USE ONLY -ail <br /> Date Area �" i. " <br /> Application Accepted byvz- <br /> fes., ..Final-Inspection —Deis <br /> Inspection b Date -_ ; <br /> Pit or Grout Inspec y w L S VLJI <br /> .. <br /> Additional Comments: I NDE;, 0� , <br /> pelican R to n all copies San Joaquin County Public Health Services <br /> d Environmental Health Permit2009, Ses <br /> 445 N San Joaquin, P D Box 2009, tkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'No. <br /> INFO CASH <br /> ♦ Ek 13.24litty, L "0-0 ` <br /> ew 111.36 <br />