Laserfiche WebLink
i <br /> APPLICATION <br /> SAN JOAQUX14 COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIItOMMTAL HEALTH DIVISION <br /> 445 X SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 1?E I iIT X 7F'TDt Q l uF k'I�Oh� [SATE TS5(lEb <br /> (Complete in Trip,llaftte) <br /> ApPliantlon in hereby made to Ban Joaquib County for a permit to Construct and/or inotall the vork herein deecriaad. This <br /> application is made in CCeopllenCe with Den .toaquin County Ordinanco NQ. 549 o.nd 1862 and the Rulee end Hegulatlona of San <br /> Joaquin County Public Health eervlceu. �1,� J �` <br /> _ Job Address ..�/ ��-�l, fl -14/f .�. ^_ Ciry- � Lot 91 se/ACreagP <br /> Owner'c NamaKi& Addiess T� s � <br /> t .�... r_�Phgno _. <br /> Coil iraClor ilddress ~nom � j t;'. License yo, x( :71' <br /> Phone <br /> TYPE F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION L7 Out of' Bervice Well ❑ <br /> PUMP INS17ALLAT10N /,,-�jrSYSTEM REPAIR El OTHER ❑ NbhiLoring Well Q <br /> DISTANCE: TO NEAREST; SEPTIC TANK SEWER LINES - DISPOSAL PLO. PRPP. LINE <br /> FOUNDATION _—_ R AGRICULTURE WELL T,, OTiiER Ir/ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> f7 Irtductrrot p Opwn Bohom ❑ Mantaca Dia: of Well Fxcavatlon,�. � Dla_ of Well Cooing <br /> bomoolIC/Privote CI Gravel Pack 0 Tracy Type at Casing­-- <br /> ['11 <br /> asing, -=-f') Public 0 Other fl Della Daplh of Grout Seal Y Type of Grou11_— <br /> I I Irrlpatlon Approx, Oepth I I Eastern $ufftoo Saul Insloled by <br /> Repair Work Done U Typo of Pump r r H,P, __ _ .� stare work Done <br /> r� <br /> Well DaalruCtibn ❑ Well Dlarnaler �f &,Llintt Haterial h Depth <br /> Depth 1 P111ir Material d Depth f J 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODIYI�AN I I DESTRUCTION I I INO aepl10 syotdrn perrnitiad 1[public rower ei <br /> evallahle within 208 lent,! <br /> Ina1011®rron wily serve: Relidence_— Commercial � 011ier <br /> NumbOr of living unit®: Numbor of bedrooms <br /> CharjClef Of sol[to p Cloplh of 3 feel: Water labra depth <br /> SEPTIC TANK ❑ TypolMig CApaCity No, Compsrlmanta <br /> PKt3. TREATMENT PLT.❑ MalhO4 of bfspoaal <br /> Distance io nearest; Well . Foundolion _ Property Lina <br /> LEACHING LINE ( 1 No. & Length of linea Total length/eize_ <br /> FILTER BED fJ Distance to naarefil: Well Foundallon --- Property Line <br /> _ I <br /> SEEPAGE PITS 11 Depth --Size �_ Number <br /> SUMPS t,t Distance to noarelt: Well FounBalion_ Propsrry Line <br /> DISPOSAL PONDS ❑ <br /> I hereby conlfy that I have prepared ibla appllcrbt(pn end that the work will be done In eccordance with Sen Joaquin county ordinancae, state laws, and <br /> rules and raguletloru of rho Sen Joaquin County <br /> Home owner or 11 canoed agent's sione(ure oertifles iho foHavirig: "I certify that in the oeridrmanae of the work for which this permit ie issued, I shell riot <br /> employ Any person In such manner tet to boogmo wbjeot to workman's Compensation laws of Collfornia."Contreclor's hiring or sub-eontracdng olgnature <br /> COMMON 11110 following: "I Ceitify(hat in the parformanoh of the work for which this permit Is Issued, I shall employ paniom aubjecl to workmen's comenaa <br /> lion f'ws of CAIIrINnia." p <br /> The applVtenLTyjt I`requir ona. Complete drawing onraver side. <br /> Signed s. 1��� "�Ut14: T l/J '�cic'1 <br /> FOR DEPARTMENT USL ON <br /> Application ACCopted by •___-ce.—Q Pate ,gran <br /> I'll or (trout Imipactlen by Dare Final InOpaellon b Det+ <br /> Addiubnsl Cort/menty: _ <br /> ApnliCant - Return all copies to: San .74ngiela County Public 1[ealth .S'erti Lee(j T <br /> Environmental Health Perpnit/aervloos <br /> Q 445 N fan Joaquin, P O floe 2000, atkn, CA ng j ,A <br /> ((JJ FEF AMOUr�T ptJE AMOUNT REM11�YED '�/`+ <br /> (Nf0 H RECEIVED BY p yp <br /> L'~ <br /> i}I 13-24(ACY, <br />