Laserfiche WebLink
S - <br /> P� APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONUENTAL HEA fH DIVISION <br /> 1601 p. O BOX 2009AZELTON f,VS'TOCKTON, CA095201YS420 <br /> (Complete in 'triplicate) <br /> Application to hereby asde.W fan JOth San <br /> County for a permitOrd to con atruct 54 a" 1 ina�theRuleshaaBeRegclations Of Sane <br /> opplicatloo is made in cmyitanee with Seo Jaapuia County Ordinrrtce Ko. 5+9 M1r7d iI <br /> Joaquin. CountY Public Health Servicer. <br /> Job Address <br /> City�� Loc Site/Acreage <br /> ls.� 14-_Q1 L�Ca P. Address'3irev W AtANEDA un NK C Phone <br /> -2C2 <br /> Owner's Name �--�- p-727 <br /> _ 3.3 33 rr � `RAcec�,icsnse Ne, 5s�i979 Pho <br /> cT NA Mal DIV rh Address <br /> Contractor E -�--�-- Dk <br /> WELL REPLACEMENT a DESTRUCTION C7 L,+t of Service Olen ❑ <br /> TYPE OF WELLIPUMP; NEW WELL OTHER ❑ Honitorir Veil <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR a [Z WC[c s} <br /> DISPOSAL FLQ. PROP,LIENEE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - OTHER WELL PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEMREA CONSTRUCTION SPECIFICATIONS^ Dim.of well Casing x n <br /> � ❑Open Bottom Woo E❑Mantra Qrs•09 xcavat on�i_ ��L---- <br /> -- ❑lndustrwl Type of CasC e Speciricaiions r----�-- <br /> Fj4 Domesi.clPrivste ;R Gravel Pack <br /> JO Tracy / Type of Glaul� <br /> - 17 Other n Doha Eleptn a!(tour Sea! �� <br /> I't Public <br /> I I lrrKpison —A.^Woa•Depth I I Eastr. Surface Sea!Insulted by �•, <br /> N.P. State Work Gone-- <br /> Repair Work Done U Type of Pump Sesling Material i DePth <br /> Wet!Dastructian ❑ Well Oiarnatu —�-- i <br /> Piller Material E.Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REpAIRIADDIDON i I DESTRUCTION i I avaitabet within 200 lest.Ied i!pubic sewer i5 <br /> Insuhrion will serve: Pesidence_ Comrnereial Other <br /> Number of living units: Number of bedrooms Water 12t"depth <br /> Charettar of moil to 3 depth of 3 feat: CaprcityNo.Comparunants <br /> SEPTIC TANK ❑ TvpelMlg Method of Disposal <br /> PKG.TREATMENT PLT.{] Found Property f ins <br /> Distance to nearest: Well _ <br /> Total length/size <br /> LEACHING LINE CI No.6 Length of lines property Line <br /> ❑ Distance to nearest: Weft Foundation <br /> FILTER BED <br /> pe y <br /> Sirs Number <br /> -' SEEPAGE PITS I I Depth property Line <br /> SUMPS <br /> LI Distance to ruxresl: Well Foundation <br /> DISPOSE kL PONDS 0 <br /> I hereby cern!!that I haus prepared this application and that the work will be done in accordance with <br /> San Joaquin county ordinances.stars laws.and' <br /> rules and regulations of the San Joaquin County g.„ <br /> Home owner orw^�Ln ehggntnnsign eorbeeomo subject follow o ariman�mcpmpensai on laws aOf aiifoania�Contractowork tot es hiring oich this r wb-eontrmit it�raclinglta9 stOh"ove <br /> employ any per <br /> ctvtifies the following:..I unify that In the perforR&MO o!the work for which this permit is issued,t sIVII employ persons subject to workman's compensa• <br /> lion laws of California: <br /> The applicant must orb for ag rmiuired i tions.Complete dr Title: Dale: <br /> an revers skid. / S� <br /> Signed a. <br /> � Tills:�a G 4ZL--d LG4/ t �� -i�f/-- <br /> a14 �' v �� FOR DEPARTIAENT USE ONLY <br /> Arsa <br /> AW,4stlon Accepted by <br /> pit of Grout Irwpectlon t7 <br /> Data Final Inspection by Data <br /> --'--....-Additional Cornrnanta:-. <br /> nty <br /> ReLlth <br /> Applieunq- <br /> Return all Copies to: Servi�cts. rlsuin ••Onwntal seslth Fer=n/"Services <br /> 1601 L. NA%Clton Ave., P 9-jilo� 2009. Stockton. CA 95201 <br /> FEf I AMaJNT DUE O.N-1 REMITTED CASH RECEEIVto BY RATE <br /> INFO 7. <br />