Laserfiche WebLink
I/a �/Q/, /O/nit. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,lam <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3400 <br /> P 0 BOE 2009, STOChTON, CA 95201 <br /> PERMIT EUIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Awileatlon is hereby mile to San Joaquin Co,nty for a permit to eonetruet and/or install the vola herein described. This <br /> appJeaylication Is md*uin Cortnt.T PUhl1a BaaltolfiaCeleaah Ban Joaquin County Ordt weee Ko. 549 aril 1 and the Rules and Regulatlme of Ban <br /> il / .4p✓SOP-sm-is <br /> Job Add,ay (/(/ `�—/ ��J��t'J�t�(�J A A�C„y _D_ Lott SSiit�te//Accrr)ea`gee LOr 0z QK <br /> /� dA Crest • / •0, Y�X 9l ?/.!r PtwM �6 <br /> bRNdSF 91 LKrn[e No. In <br /> YPE OF WELLUPUMP. NEW L ❑ WELL REPLA MENT n DESTRUCTION Out or Service all LI <br /> RUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O liooiwrtrd veil LT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL MTS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ii InOustr41 E] Open Do”" C Memece Dia. of WN Escanitinn Dia. of Was Cewng <br /> (I Domest4lpl sle ❑ Gnval Pack ❑ Tracy Type of Caairq_ Spetftetrora <br /> i'I Relic I:1 Other fl Dalt, Depth of Grout Steal Type of Grout <br /> I I Inipatgn _Appo+. DePlh I 1 Eanarn Surface Seal Installed BY <br /> Repw Wort Oona v(J�y Type of Pump Ti H.P. - Sen WM Dona <br /> WN Destruction Pl Was Dianater __�r Sealing NsNrial a Depth GJy / <br /> Depth /� Piller Material A Dalen <br /> TYPE OF SEPTIC WORK: NEW INST.c11ATION I I REPAIR/ADDITION I I DESTRUCTICA I I INo tepnc eyONp pe t;ko H p bkc sewer a <br /> "&de s velNin X10 fMt.I <br /> Installation less MM: Reeidarrce_ Commend_ Other <br /> No show of living units:_ Number of bedroom, <br /> t Chencnr of eat an a depth of 3 feel: ... Waly table dapM <br /> SEPTIC TANK ❑ Type/Mfg "Oaciry No.Corrprtmrna 0 <br /> PKG.TREATMENT PLT.❑ _ Method of Disposal Q <br /> g Oiatance to nspest: we Foundation Preciosity,Line <br /> >, LEACHING LINE 0 No.S Length of Host Totes lengthlount <br /> FILTER BED n O'utance to nest: Well Foundation Property Lire <br /> SEEPAGE RTS 1 I Depth __Sir, Number <br /> SUMPS LI Dlelsone to nooni WN FouMalion Property LM <br /> DISPOSAL PONDS O ' <br /> 1 hereby cinOV that 1 hM geared this applKnwn and that the work win he done In accorante in San Joaquin county pdeancea. ,late IMI.end h <br /> make and reputations or the San Joaquin Couoty <br /> Home ower w kcerrW apenl's signature oendiat the following: "I ratify that In the performance of the work for which tees panmt Is lewd.1 else nor p$ <br /> ornploy any person A such maensr as to beco ne tubect to workman'•coopengtion lawq of Cakforrka."Contractor#hiring or euDeontractinp wonstue <br /> pentdlee the following:"I Vanity that M the peAormsKe of the work fp vilte his pMmfl 4 issued.1 the[employ persons subject to workm 't co pone, f�a <br /> tion ales of CYNomle." f�j <br /> The epplk 1 kked` 0�,�CkompNn dntwing on N elQg, n <br /> gored It �fly /71`�7irRirl.. /�.�.�+ i(/ Dote: 9 e <br /> �n1 OR PARTMENT USE ONLY / Fi <br /> Application Accepted by v .Date v� Ares <br /> I <br /> Pk ce Grout Inspection by Data Final Inspects by Data 2' '♦ <br /> i ` <br /> AddNlonsl Cornesnts: <br /> Applicant - Return all coplen to: San Joaquin County Public Health Service. <br /> Environmental demlth Permit/Service+ <br /> a15 H San Joaquin, P O Box @009, Stan, CA 95901 <br /> IMIU AMWNT DUE AMOUNT REMITTED I CASH AtCEN1D ay / DATE P[RMT NO. <br /> IN�,■ <br />