Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SHaVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Jor.quin County Ordinance So. 549 and 1562 and the Rulea and 111094111111,101110 Or Sam <br /> Joaquin County Public Health Services. <br /> Job Address �! rJ" p ii rpF J — C.tr �y/ 1�fL_ LOt Slse/Acraase d C <br /> Owner's Name <br /> (� /1 /1 ��/��D D Addresse <br /> L u� Address 2a t fREWEBT license No. Prion. <br /> Contracts�.�1y1�-- <br /> TYPE OF WELL/PUMP NEW LL O WELL PLACEMENT Cl DESTRUCTION O but of Service u Q <br /> PUMP INSTALLATI O <br /> YSTEM REPAIR ❑ OTHER O IlatiteritaS Yell <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLO. PROP.LINE <br /> FOUNDATION AGRI L LIRE WELL OTHER WELL MTS/SUMPS _ <br /> INTENDED USE TYPE Of WELL PRO EM REA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial O Open Bottom O Man a Dia. of Wes Excavation Die.of WON CSOV <br /> f I Oornesuc/Fnvsie f7 Gravis Pack ❑ Tr y Type of Casing_ SPatMkatbM ; <br /> 1'1 Public I I Other n is Depth of Grout Seal Tppa d Orwt <br /> I In•Uauon ApIkox. Depth Eastern Surface Saw Installed by - In <br /> Repair Work Done U Type of Pump H.P. State Work Dae_ <br /> Well Destruction O Well Disrnater <br /> Beal IEsterial A Depth - <br /> Depth Tiller tenial • Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 1 INCt feet ted H pitbfitc eavrer r <br /> Installation will serva: Rssidsnca.� CORvtMfCial^ Other <br /> Number o/living units: _L_ Number of bedrooms i— / <br /> yp <br /> Character of roil to a depth of S feet:� 1�en Wats tabor depth ` <br /> SEPTIC TANK O Te/Mfg CapacRyi,aL10t No.C.mtrt0arillmiliti <br /> PKG. TREATMENT PLT.Cl oe % 1P Method of Disposal <br /> Distance to nearest: Weis 5JZ Foundation_!_!_— Property LIM A�r <br /> LEACHING LINE C1 No.•Length of lines 2— Total length/eirli <br /> FILTER BED f7 Distance to nearest: Won 11104P Foundation / Property Line <br /> SEEPAGE PITS I I Depth _Sin Number 7 <br /> SUMPS LI Distance to nearest: Well_ Foundation Property Lina <br /> S <br /> DISPOSAL PONDS O k, <br /> I hereby comity that I have prepared this application and that the work will be done in accordar ce with San Joaquin county ordinances,state laws,and 1 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 'I sonny that in the performance of the work to,which Mn permit is Issued.I shall not <br /> employ any person.n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or eub•contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's t:ornpww- <br /> tion laws of California." <br /> The applicant must cay for aha required In SW a. Complete drawing on reverse sial. <br /> Signed% Title: 01 ,M I r Data: <br /> FO DEPARTMENT USE ONLY f <br /> ,2—Ares <br /> 1 <br /> Application Accepted by <br /> Pit or Grout inspection by Date Final Inspection by ' Date <br /> Additional Comments <br /> Applicant - Hoturn all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 446 H San Joaquin, P O Boa 2009, Stkn, CA 93201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By OATE j <br /> /a�� <br /> FN;3 24 IxN . �'+� S INFO 1 vy f • / �/ <br /> FN t638 J <br />