Laserfiche WebLink
APPLICATION FOR PRUIT <br /> SAN �QU'N COUM PUBLIC IC HSALTH 4VICRS <br /> ENVITTAL HBALTS DIVISION <br /> 445 N SAN JOAQIIIN, PHONE (209)468-34201--1 <br /> PA YMEN� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RECEIVEDIMIT RrPTHM 71 YE DAA& ISSUED . <br /> (Complete in Triplicate) AUG 2 0 19o3 <br /> Appliastian is herd1w am& <br /> �iaW Joaquin <br /> aq County for a gamut to construct and/or install y� SAN} t1N CWOTY15SION <br /> i <br /> [r�iloation is rade in Joaquin Counts Ordinance No. 549 and 1S& and tlEiFV <br /> Joaquin County Public Snaith Services. )wow <br /> Job A&Wes IF-. E/ bo a St.. <br /> Cityc��`�Di7 Lot Sine/Acreage <br /> Owrnrs NOW Addresa 77/1('4i�► �t.�lf`�-rttt, Sr�1�t.8d a / �If /'7O <br /> T <br /> SrS�/h'u� f�;�e <br /> C-5p P%x41 <br /> Contractor IG�N'!E*iC ass 7 se No. Phone Cs ro <br /> 1-2 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Be]l <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Of Monitoring well or <br /> DISTANCE TO NEAREST: SEPTIC TANK `- SEWER LINES /40 fZt DISPOSAL FLO._ejd PROP. LINE A9_*A <br /> FOUNDATION -19t-ft— AGRICULTURE WELL OTHER WELL--* 15r. PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ec A'r°"c"y d-6 fjw'otaS) Q <br /> n I„auprlal a <br /> ❑Open Bottom ❑ Manteca Qin. of �P�von s Die. of Weil Canute <br /> n Domaft/Prbate ❑ Grahrel Pads ❑ Tracy Type of 15 ics lions .o <br /> Public fjr ZO .� <br /> Il Pubother�r n DNta <br /> I I ��� �# Depth of Groes Seal Type <br /> Appr�Y. bepth 1 1 Eaeurn Surface Seri Inetskd by Ar � Q\ <br /> Rspsir Work Dons U Type of Purnp H.P. State Work Done <br /> Wall Deeffuction ❑ Wal Diannter SMKXU g N■terial A Depth <br /> Depth Miler Naterl" A Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I 1 1*septic systarn permitted it public sewer is <br /> aysilabb within 200 feet.) <br /> 1naabdon will ss+rve: Residence_ ComnsmW_ other <br /> Number of Ilhi"WdM Number M bedrooms <br /> Changer of esu to a depth of 9 het: <br /> Naar labia depth <br /> . SEPTIC TANK. ❑ Type/Mfg Capacity No. C.ompertnnnts <br /> PKG.TREATMENT PLT.❑ Method of Dispossi (� <br /> Distanes In nsarret: WON Foundation Property Lira <br /> LEACHING LINE ❑ No. i Length of*us Total length/ <br /> FILTER NO 0 Distance to nearest: Wei Foundation Property Line <br /> SEEPAGE PITS I I Depth Sias Number <br /> SUMPS LI Distends to Harvest: WON Foundation Property Line <br /> DISPOSAL PONDS p <br /> I hereby cor Wy that I hove prepsred this apokedon end that the work will be done in accordance with San Joaquin county ordina wn. state ktwa, and <br /> ROM end raghrlations 01'910 San Joaquin Caunty <br /> Mane owrnr orl-w- d agent's iipnslure OBI%iA r the folowing: "I eartify that in the perkw lienee of the work for which this permit is issued. I dW not <br /> empioy,any person in such manner as so' -m -e subject te workman's compensation laws of Caifornia."Contractors hiring or VA"onawtkhg signature <br /> 8-0-a dN foNoolk "I certify that in the performefte of the work for which this permit is issued.I aha)empby Persons subject to wo*rnm's aompen". <br /> ton laws of Cdkwr a." <br /> Tin all ions. Complete drawing an rOvene side. <br /> Titer: Date: }}� }} <br /> Signed _ /vf T 4� <br /> FOR DEPARTMENT USE ONLY A <br /> APpkatktn Accepted by Cate 3 ASN -��JE <br /> Ph or Grout Inspectim by Date Final Inspection by Data <br /> AddNo"Comnsnte: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services / O� <br /> Eovirosrestal Health Pewit/Services <br /> 445 N San Joaquin, P O Box 9009, Stkn. QA 93201 <br /> F AMOUNT DUE AMOUNT REMITTED pCAS� '/RaYLECMID OATE PERWT'h0. <br /> OW.1-4461 °G Q'" t b1 Imp <br /> art toss <br />