Laserfiche WebLink
I <br /> ' APPLICATION FOR PERH�IT U, � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1111 <br /> �Fly <br /> ENVIRONMENTAL HEALTH DIVISION Vv <br /> C✓(�'' P o sog zoos, STOCSTON, cis ssaoi OCT 3 0 1992 <br /> (209) 468-3447 I <br /> 2E8!(IT E%PIRES 1 Y a )IRON DATE ISSUED ENVIRONMEfYTPJ.HEALTH <br /> f <br /> (Complete in Triplicate) PERMITISERVICES <br /> Application Is hereby made to San Joaquin County for a permit to construct an <br /> ld/or install the work hereiq described. This f <br /> Joaquin County <br /> !e made 1n compliance Services. <br /> ces. San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Couaty/ Public Health 9arvJicea. 1 �1 <br /> Job Address —L 53 Y C'1M t.l Q.1-�f T ( j Y• j _ <br /> /� 'I � ,� City I 1 , �LC�Lot 91ze/Acresge <br /> Owner's Name C /1.I W�(�S� OfWl(tl`Q-4P ( rA�lbreis�� lYttE� i <br /> i <br /> Phone <br /> contractor ti �i i' <br /> Address• .35 I=, M 41e. `7F. �� 51 a3(pS 4(v — Cp <br /> (License No. Phone <br /> TYPE OF WELL/PUMP: NEW-WELL 0 Service Well 0 <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT iOESTFIUCTI -'a''l./ t or <br /> Well. <br /> bl <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES OI 'T OSAL FLO. PROP. LINE <br /> FOUNDATION ER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA .1 NS n 11�' <br /> 0 Industrial 0 Open Bottom Manteca Dia. of Well Excavation'( Cis. of Well Casing 2PVC <br /> V^ ` <br /> U Domestic/Private 3(Gravel Pack ❑ Tracy Type of Casing PV 'Sch. ¢Q Specifications <br /> 0 Public " 1'1 Other C3 Delta Depth of Grout Seal ��� '�- Type of Grout <br /> Cl Irrigation o ApMos. Depth ❑ Eastern Surface Seal Installed h_v OF r"-fY1LVYY <br /> Repair Work Done 0 Type of Pump M.P. State ork Oona_ <br /> Well Destruction 0 Well Diameter Sealing Material a Depth 9 <br /> Depth Tiller Material i Depth If <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION M DESTRUCTION 0 (No sepirc system permitted if public sewer is <br /> h available within 200 feet.) <br /> Installation will • Raaidence_ Commercial_ Other <br /> Number of living units: _ bar of bedrooms <br /> Character of sod to a depth of 3 feet: iter table depth <br /> SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 - ' Method of Disposal I <br /> Distance to nearest: Well Founds I Property Line <br /> I� <br /> LEACHING LINE ❑ No. g Length of Toial len ize <br /> FILTER BED 0 Distance nserest: Wall Foundation Property LI r 1 <br /> SEEPAGE PITSDepth Sire Ndmber <br /> SUMPS LI Distance to nearest: Well Foundation �I Property Lim <br /> DISPOS PONDS ❑ L� <br /> I hereby certify that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County it <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring of subcontracting signature <br /> canities the following:"1 certify he in he performance of the work for which this permit is issued. I shall employ persons subject to workman's compenu- <br /> tion laws of or la:' <br /> The app)' "lost telt for r Ins mplete drawing on reverse side. �- <br /> Signed Title: 'f+lo.� f-6Aio. 5� Date: <br /> I o-,FFOa'R./sDDEEPARTMENT USE ONLY L� ? <br /> Application Accepted by Ul.��t�MTcl\ pall �^ I—i ASN <br /> Pit or Gr spection by Date Final Inspection by Date <br /> 1 � 11 1 <br /> Addhlon o ftlanfnn: % l <br /> if <br /> Applicant - Rftgn cAP� <br /> oP • c 9 AQUIN CO ELIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES /�'I�'�f� ��\''??----'..�� <br /> 443 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 93201 /`-", S ' <br /> li <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE <br /> : PERMIT'NO. 1 <br /> . <br /> IN 117.IaN.r/oar -/.� <br /> IH:0.y [ <br />