ARCHIVED REPORTS_XR0009417 - Laserfiche WebLink

Home Browse Search

APPLICATION Fd1Z PhE11fIT �eno25go Sil-N JOAQUIN COUNTY PUBLIC HEALTH S V S ENVIRONWENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468 0 P O BOX 2009, S rOCITON, CA 952 IFAC y#. f„•` EZRMIT fMIRES I YE R fr (Complete in Triplicate) Application 1■ hereby sde to San Joaquin county for a permit to construct end/or install the work lercln described. Thin eypliestloo is wade in eeapllance with San Joaquin County Ordinance Ro. 549 and 1062 and the Rule■ god Regulations of San Joaquin County Public geslth Services. I Irot Size/Acreage <VC fr Cd• Addese G�u•*'� CA yftS2l- Ze7z Pnana o � *a 3L�r r��rrgqwl� ld, sf4 � LaZ•�zd Pnon(yK B52'r`f4Sil �V r f r/ac, Address A- u"�'"!`�� -License Na, Service Conlfr-t v Crr-e• . •� • - v NEW WE'-L.0- WELL REPLACEMENT fl DESTRUCTION L7 Out of Yell ❑ TYPE �., �.f'Z.I I OTHER 0 klonitoring Yell p N PUMP INSTALLATION C1SY5TEM REPAIR ❑ r 1 2'5"E' ' SEWER LINES 7 I DISPOSAL FLO.7r PR(IP.LINE"� DISTANCE 70 NEAREST: SEPTIC TANK : ' FOUNDATION 7�r -- AGRICULTURE WELL� - OTHER WELL T r UMPS Xf&d-d � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // 2 r, i- - n Bottom CltlAsmeca Dia.of Well EscsvatioA may•of Well C+sin, - I` L7 Industrial ❑Open IlIG Spacilk.stiom 's`4��— 4 Ll Industrial rivate Ll Gravel Pack 0 Tracy Type of Casin,_�.r Type of Grata c. [e m"tf I'1 Public *Ot►br rT Delta Depth of G+our Seal f ! r - I I litigation ZLr Apprax.Depth I 1 Eastern Surface Saul installed by Rpair Wort Dane U Type of Pump H.P. Sure Work Done — _� k Well Daairuction ❑ We*Diameter Scaling Material i Depth � s Tiller Material i Tlepih f - - Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I : REPAIR I ADDITION I 1 DESTRUCTION I I avail GN�wlhin 200 loot.)rrd it public sewwr u hutseslbn will serve: Residence..r Commerclal_ Other :r Number of tiring unlla: Number of bedrooms Water table depth Chracut of WW to a depth of 3 lest: No.Crxnrrrn4 K SEPTIC TANK. ❑ Type/Mfg Capacity Wrt MCG.TREATMENT PLT.0 Method of D sal r Distance to nearest: Well Foundation P•operty L'u,eRf C F I a LEACli1NG LINE - Ll No.i Lan,th of lines Total len,thlrirai� f s f Lina FILTER SED ❑ Distance to nearest Well Foundalion PropertyONMENTAL ,j�tyf 4 s SEEPAGE PITS I I Deplh Sin Number F SUMPS LI Diaunce to nw9st: Well foundation Property Line % t. "'(DISPOSAL PONDS ❑ r l} I hereby earthy that I hew prepared thin appl talion and that the work will be done in sccardance with San Jo+qul:t county ordinances.+tete levee.end k rulse end repulallar of the San Joaquin Couaty r Nome owner or Rosnsad apent'o,sl,nature artifices the lollowin,:-1 certify that In the performance of the work for vMkh this permit Is ksued,1+hell trot emptor'arty person kt such manner a to becalm subject to workman's compensetion laws of Csufornta."Coneueto's hiring of wtreontraetin,,yigrytuq Ar ertlft s tel fpeowin,:"I certify that In tel puforrhance of the work for which this permit is issued.I shall employ parsons subject 10 wortiman'a comWn++ r tion Isw of Cofrxnls." ( , The spplWnt _/ct call for+N cogtuieired In�s7p/oclions.Complete drsNinp on reverse side. l F .r"°��-.� �. i�C l— TIIIe'. ! • r D+te: 3 �a Q f Sig, Y r FOR DEPARTMENT USE ONLY a- LA rea �r .I Application Accepted by Dat• ' it pk at 6rouf inspection by. Data FI pection b DatezL Z Addltion ll COM-MMI: -�L A lie ant ^ Return all copies to: Sao Joaquin County Public Haalth Ser ces pp Environmental Honllh Permit/Services { 445 H Sao Joaquin, P 0 Box 7009, Stkn, GA 43201 C RECEIVED SY DATE M I FD AMOUNT DUE AMOUNT REMITTfD CASH T 4 I