Laserfiche WebLink
APFL I CAT I t?N FOR PERMIT/ iG�L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S8011CTS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 Bog 2009, STOCKTON. CA 95201 <br /> (209) 468 ` <br /> rMIT � AR kROM z ATA 122U�.n NOV 2 7 1991 <br /> (COMPleite iI Triplicate) <br /> Application is hereby m6de,to Sans aosgUitr County for V#rstitr to construct anId/or inetall the vor dj <br /> application is made in ccmrpliance vith-SSW Joaquin County Qrdinance No. 549 and 1862 Arai the Aube 6.1 <br /> Joaquin County Public= Services. <br /> 7 <br /> Jab Address, r �'/ .. .e lf/ j�J` �ffi�! �' c;ty Lot: SI:e/i areage:. 'L% f y <br /> Owner"i Narne :, ; C' ��/ I7 Address +� .?'iv/fi/V � ,' lshCn � /�"�`"��c <br /> cTi .f C <br /> Address "/ �� � Phon <br /> + •loo ,i'Ye�'C/ rcense No. .�.... .. <br /> =TYPE WELLIPUMP.: N9W WELI..154 WELL REPLACEMENT t'1 'I DE.STRUIMON :L7 0ut of Ser.y' ce Well Cl <br /> PUMP'INST*LLAT"o d; SYSTEM REPAIR C1 {`JTHEtf 1 JtGr t ni.A', 'AW <br /> C7::: <br /> DISTANCE `O 4EAREST::'SEPTIC,TANK:' SEWER ONES 0100SALFLID:. PROP. UNC. <br /> FOUNDATIQN..: AGRICULTURE WELL OTMER W€LL. PITSISUMPS <br /> INTENDEQ'%2!1 TYPOOF WEIL. :PROBLEM AREA: CONSTRUCTION SPECIFICATIONS <br /> n Induatriat ©open Bottom .0 Mantoda {}ia. of.Well Excavation.! Dia: of Well Cooing <br /> tJ 00MOS060r'n/ete 0 f`ararral Pack: C� Tracy Type of Casing S.pectf+cattgetilr': <br /> LI PutJl <br /> ft Other .O Oalta iOipth of Grout Seal t TVps of Grout <br /> tJ 1rrgxtion >& .. Appros. Oap.th 0 6starn Surfice Seal Installed b.v <br /> Repair Work Oona t] Typo ot:'Pump IHIA Stat*,Work Gfone._ <br /> Wall Destruction Cwall( aratrSealing YAterial i Depth <br /> (� <br /> r i <br /> Depth Filler Material i Depth " <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR1*06.1TINT-7 DESTRUCTION CI INo septic system permitted it public sewer is 5 <br /> r a40486te within ZtK}feet.) <br /> Wtallation wt1I 4erve Residence_. Commtircial,,_,_ Other �. <br /> Number of living units: Number of bedrooms 9 , <br /> Character of coil to a depth of 3 feet. Water table depth <br /> SEPTIC TANK L7 Type/Mfgcapacity l No. Compartments <br /> PKG. TREATMEl+7T PLT.CI Method of Oisptosal Y <br /> Distance to nearest: Well_,, foundation Property line <br /> LEACHING LINE L'l No. 3 Length of linea Total length/size <br /> FILTER BED 0 Oistsnce to nearest. Well Foundation t Property Lina r <br /> t <br /> ,SEEPAGE PITS t I Depth Size Number- <br /> _.5UMPS_. .. :•Lt Distance to nearest- Well Foundation C Property I Ina T <br /> DISPOSAL PONDS O'. <br /> I hereby certify that,11 have prepared this application and that the work Will be done in acco da ce with San JdAtIoWcounty ordinances,*tate laws, and' <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I Certify that in the performance of the work'fcr which this pernit is issued I shaltnou <br /> employ any person in such meaner-as to become subject to workman's compensation laws of California:"Contraatof s hiring or subcontracting signature <br /> candies the following:"I certify that in the performance of the work for which this permit is issued, t shall employ persons xubjec to workman's+compenss- <br /> tion laws of California." <br /> The applicant mus of lair s Complete drawing on reverse side. t T <br /> • ,rr <br /> w. <br /> ;Signeit �Titler t t?ate:. f <br /> OR I'EPARTMENT USE ONLY <br /> ta <br /> Application Accepted by. .- Duto AN j <br /> Pit of Grout dnapeetiott b.. Date.. ., Final Inspection'y Otte.. } <br /> Additional Comniartta; <br /> !j <br /> Applicant :Rituxss 41 Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ..2110lttlNtdSNTAL HEALTH gIVISION PER113T/S13RVICSS <br /> iii:N SAN.•JO*QU'IN., P! 0 BOX '2009, 9TOCXTONr CA .95'3'01. <br /> FE CK INFO AMOUNT DUE AtNt7UN7 REMITTED �SN ItECEIWEQ ay DATE P�AMIT'rrt t <br /> . tM 13.24 tRftil:is:est } <br /> EN:h2e <br /> l y <br />