|
A .f APPLICATION
<br /> k' :t
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '
<br /> ENVIRONMENTAL HEALTH I]IVIStoN
<br /> 445 N SAN JOAQUIN, PHONE .(209)468-3420 O
<br /> 5 P O BOX 2009, STOCSTON; CA 95201
<br /> o �$.
<br /> ?SMIT .EgPIRES 1.,YEAR FROM DATE,..ISSU$D..,,,: a .• . y
<br /> (Complete in Triplicate) r
<br /> A Carlos le ,hereby tnade•to San Joegiii t Coutnty for a peralt`to construct and/or ittataLl`t;he''irorrk bekein desCribed:P This
<br /> rcpplication 16 rnatie+ia coaplianee with San Joaquin County'Ordinance No: 549 and 1662 a- theme es and Rigulatione of San
<br /> Joaquin County,Publie Health Servieee..M
<br /> VIP-
<br /> Job Address ` ~ r ' Ciiy � Lot Bice%AciebgeWill
<br /> " }
<br /> Phone
<br /> .Owner'sName
<br /> ' .. reSS1�.a7.d.-----
<br /> dA, 1t t+ r y.
<br /> Cantraclar - Add7ess _ License NPhone
<br /> o,°;, ^'
<br /> TYPEOF I+VELt/AUMP;x-..,:r NEW WELL C] WELL REPLACEMENT C1 L} STREJCrTIQN P Ns, of Aservice Veil
<br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 t � �O��I�H ® �,Mani tgr.tRg`HP11
<br /> DISTANCE 7O NEAi�EST: SEPTIC TANK SEWER LINES DISPOSAL FLO.".._., PAOPjLINE
<br /> 4: ": FOUNDATIONs ... AGRICULTURE WELL OTHER,WELI . fes_:`P1TS/5UMP5
<br /> a '
<br /> INTENDED USE '< TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t
<br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "
<br /> DI■: of.4iVall&sing
<br /> f.l Domestic/Private ❑ Gravel Pack '4 'NL]`Tracy Type of Casing._ :: . .. Specifitations' "
<br /> f•I Public 1-1 Other. P fl Delta Depth of Grout Seal Type of Grous'
<br /> I I Iris alien '' A -
<br /> tl , pprdx. Depth I I Eastern Surface Seal Installed by p
<br /> Aepair Work Done 0- Type of Pump.; H.P, Stam Work Done
<br /> Welt Destruction .0 Well Diameter- Sealing Material i Depth + ��
<br /> i> Depth F111er Material i Depth
<br /> TYPE OF SEPTIC.WORK:. NEW INSTALLATION I I REPAIR/ADDITION 1, 't)ESTRUCTIONJ No septi ysterrt permitted-ifpubkc
<br /> available thin 200 feet.! +,
<br /> Instaftetion will serve;r'ResidancA '''Gilrnmercisi Other r
<br /> Num" e4of riving units: Number of bedrooms t # I ,
<br /> Character 01'904 _p a depth of 3 fest: star tabs depth ' . . .,,i
<br /> SEPTIC TANK ".- % `
<br /> ;! ❑w•...Tl+pe/Ailfg _ - .-... Capacity No.,jCotn -
<br /> PKG. TREATMENT PCT..C7 �-�� hi4eshod of Dmann � J.
<br /> isposal ji
<br /> s Distance to nearU' Well Fo Property Line ,, �;,; , -� Iron I
<br /> LEACHING LINE. L'l ' Na: 6 Length of linea --- —� �"``� folal too9th/size '
<br /> FILTER BED n Distance to neareaO'"�Well Faunnati�a��
<br /> Property Line "
<br /> i f �r t r i
<br /> .4n • }Rr wh
<br /> SEEPAGE PITS _ I i r pth S+:e Number_ y
<br /> SUMPS LI Distance to nearest. Well__`_W______ Foundation Property Lt µ7 M *4
<br /> DiSPOSA .,C11VbS
<br /> L ❑
<br /> 4 ...• „�..
<br /> I hereb-certify,that I have prepared this.spoltcation and that the work will be done in accordance with San J66quin;eounty,t'(dinancot, still liws,_an�. �
<br /> •rr,1es and regulaliot a of the San Joaquih Countik 9 1 l fi r
<br /> Horne wn ►6r licensed agent's signature eertifiei the following: "I certify that in the periormence o1 the work for Aihleh thij permit it issuatf I ih,0
<br /> rtift
<br /> employ any person in such WAnner sk tq bitO"ne°subject to workman's compensation laws of California."Contractors hiring or sub contracting signetur`e
<br /> enrtifias the following:".1 Certify that in the performariewof the work for which this permit is issued, I irtall arinpioy lWrsont subiset to vrtAniisn'tl CompaAsa-
<br /> tion laws of California.•, .j ,„r,
<br /> The applicant.muss caR for all required Y peC6ons. Complete drawing a se side.
<br /> Signed TitleyAe
<br /> . D■1a
<br /> .� f1 bEP RTMENT.USE ONLY
<br /> Applicstion Accapl■d by bate
<br /> Pit o74
<br /> r Ci�Out Inspactiort.by.,... -'_ Date�. .�...Final Inspection by bate
<br /> Additional Comminta
<br /> App]fcaet Return all copies to San Joaquin County Public Health Services
<br /> l k :!$Environmental Health Permit/Services t
<br /> r.
<br /> {
<br /> i d 445 N Ban Joret]uin, P O Box 2008, Stkn,'CA 852011 y .
<br /> AMONT OUE AMOUNT C F ElVED BY, . D E,.,r PERMITN0.tNFfl r
<br /> • FH 1324IALV.iiAbl JJ� J /f // 4
<br /> rti 1440 / �' µ� r Yf r,1, fS .
<br /> / ,I
<br />
|