Laserfiche WebLink
APPLICATION FOR PRUIT <br /> SAN JOAQUIN COINTY PUBLIC NRALTH SBRVICBS <br /> BMXQPEIWTAL NZAM.DIVISION <br /> 1801 B. BAMTON AVE. , i"i (209)488-3420 <br /> P O HOZ 2009, S'i'OCSTOK, CA 95901 <br /> PBB1[IT XI PI 1 TF" FROM DATE ISSN <br /> (Complete in Triplicate) <br /> 4rileation Is bereW eede.to Sou JoaquaneCom"r for a permit to construct aad/or install the work herein described. This <br /> sypu stion is atde in oaplladas i to Mil.f'otian Counts► Ordinance no. 549 sad 1862 W d the ltvlea and Seat]atiooa cc Sao <br /> jesQuia Canoes Public Isola Services. .� 61�t j�.,D�& <br /> Job Address MU) d0dW DC 'FU C`� it, Lot Size/AcreW <br /> Ownersis P._ Address IMs S. Q LCtt]QY`CY_ ({� ,til• t Phone <br /> o ort e*44.18AV000el S!22to8 * 468'97 2- <br /> Contractor <br /> Contractor Address {} icenstNo.SpZE1?9L Phone <br /> OF WWJPUMP: NEW WELL a WELL RE CEMENT O DESTRUCTION O Out or Aoe [1121 <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER,Q-- Monitoring We-11 D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED tm TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Inawmrial O Open Bottom O Monte" Dis. ofAMMF Excavation Dia. of Well Casing <br /> n Domaaaic/Prbate O Gravel Pads A31acy Type of Casing _ Speoikso ns <br /> i11 PuWie n other n odes Depth of Grout Seal t5 r <br /> I I Irrigation Approx. Depth i t EsatemSurface Seal Installed byUK <br /> Repair Work Dome O Typs of Pump H.P. Stats Work <br /> Well Osarweloa O Well Diameter 8"11ag Material a Depth <br /> Depth Piller usur"i a Depthartmom -ALTH <br /> TYPE OF SEPTIC WORK: NEW ALLATION I I REPAIR/ADDITION I I DESTRUCTION f i ft memetesomeani <br /> is <br /> avaslabN � <br /> W IatIs I vti ssrw: Reeidence— Commercial` Other <br /> Numbw of kft WOW— NurrAw of bedrooms <br /> Character of all to a depth of 3 feet: Wear table depth <br /> SEPTIC TANK. O Tvps/Mfq Capacity No. Comparanants j <br /> PKG. TREATMENT PLT.O Method of t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LME 0 No.i La+gth of tines; Toot langthisin <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Sin Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lira <br /> DISPOSAL PONOS O <br /> 1 hereby cordly lima I hove prepared tis application and that the work will be dons in accordance with San Joaquin county ordinaneas.state iwre, and <br /> rules and regulations of the San Joaquin amore]r <br /> Nome owner or fearuas.apatt's sipnmture oarIM the torowirW."I certify that in the pedo"nence of the work for which this ptMtart is issued.I shah not <br /> employ any pansy in such mawmr as to become subject to workown's compensation laws of California."Contractors hiring or cab-contepidtinp sigrmwre t <br /> Pore the 1 certify that in the partommm a of the work to which this permit is issued,I shall employ persons subject to wonkmmn's gny»nw-� <br /> of CaMeenk." <br /> The call for insptetions. Complete drawing on reverse side. \ <br /> Silp - Title: Date: ��• t FOR DEPARTMENT DEPARTMENT USE ONLY / 4� <br /> APplic do Accepted by Date ! } �` Area <br /> Pit Or Groot Ingaction by Date.t G Final Inspection by Date /Z <br /> Additional Conu ems: <br /> Applicant - Setas all oopiee tot Sate Zptattsa Counq► Public fitalth <br /> 'U0 to-) <br /> Serfte", Pa. t/8ervic" L; <br /> 16011 Z. Zaseltoo Ave„ P V Doli 2009, Stockton, CA r/ <br /> MI O AMOUNT ONE AMOUNT REMITTED �C/A�SHr RECE'1YED By DATE P Mr rT-NO. R <br /> EN 74>/ <br />