Laserfiche WebLink
APPLICATION FOR PERMIT <br /> Y1r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONTAL E.'r LI���� <br /> 1601 E. HHAZELTOONN AVE. , <br /> PRONE (208 ALTH DIVISION <br /> ED <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRQK DATE ISSUED <br /> (Complete in Triplicate) <br /> Appliwtiae Sa hereby made to Bea Jw.u1a County Tor s Permit to construct mod/or install the York heel. de...lead. This <br /> eppllcatloa le mWe to ecapllaace vlth gas JeeRul. C000ty Drdiwoce so. 549 sal 1861 sod the Rules ma Reeulatiooa or Ben <br /> Jwqula ComtY Public Hea1tN Services. <br /> ta9z Jr Job Add., 1 <br /> q rfji✓2;af /GrJ Cly Lot Size/Acreage dQ0 /k <br /> Ohm"'.Name Address � . <br /> fey ,� / Phone a <br /> Conlraclw ve Addiess_�Cd! (7 Licmnad �Z/ Phone c/ J <br /> TYPE kT WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Nonitarkne Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Isdustral ❑ Open adman ❑ Mameo. ❑la. of Well Excovation 014. of Well Casing <br /> L7 Domarluel Prickle U Gravel Pack ❑ Tracy Type of Casing Specification. <br /> I'I Public ❑ OfIre, F Delta Depth of Grout Seat Typo of Grow <br /> I 111duallon _Appmx, Depth I Eastern Surface Seal Installed by <br /> Repeir Work Done ❑ Type at Pump H.P State Work Done_ <br /> Well Daehucbun CI Well Diamwar Sestuae Metelml A Depth <br /> Depth Filler Materiel A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIWADDITIDN W DESTRUCTION I I 4No septic sysnm Permined it public saws,or.calm.v�lhin woo IeeLl <br /> InstilleInstillment,will serve: Resident._ Commwca ��y"�v�v <br /> l_ Other <br /> Numb.of fining unit.. _ Numhm III lad,ao n. <br /> Character of wll to a depth of 3 fast.A""- - 4,, War.Ieble depth O f <br /> SEPTIC TANK 0 Type/hale Capacity Na. Comparhront. <br /> PKG. TREATMENT PLT.0 Method of Disposal T <br /> Distance to pemq Well Foundation Property Line Y <br /> LEACHING LINE ❑ No. 8 Length of term C// �0 Total length/else_. <br /> FILTER BED O Dime... to named: Wall 300' Foundation /D / Pmp wtv Line lento / <br /> SEEPAGE PITS IT Depth 21 Sire 3(O n Number 2- <br /> SUMPS _ <br /> LI Distance to mere.: wen oD ' Foulltletio. /0' P,oporty Lim. /?b� I <br /> DISPOSAL PONDS 0 <br /> 1 hereby cortit, that I have preparad this application end that me Work will he done in acwrdanck with San Joasu'm county ordinances, n.. Iowa, and <br /> rubs and r.guIo umat of the San Jmouin County <br /> Home owner or licensed agent's signature cealfe.the following: "I certify that in the p formancs of the work for which this permit is Issued, I.hall not <br /> employ any parson In such manner as to become subset to workman's compensation tows at CaliPornis." Conrraclor's hiring or aUP.Irmactinp signature <br /> terlifies Ins Iolthearl "I writ,Nat in The pRormonw of the work Par which this permit Is Issued,I shell employ peons subpa to workmen's camps.". <br /> Won Iowa of coltomN." <br /> The applicant mull call tar ell rgtsir�Inepaiers Complete drawing on revers. title, <br /> Signed X�v �.G nlw: ©W A)cc Date: y'/6- 9e <br /> MR DEPARTMENT USE ONLY Ja/.� <br /> Appliamfist Accepted by G7e Dale `��4- 6- �( ) Arse �L <br /> evor Grout movement by Date V-ZIT 1 L 6Final Inalramlon by -�� I m--✓ Dree Zn LO <br /> Additional Common a: <br /> Applicant - Return e11 copies tul smv Jamautin Cormty Public Rselth <br /> Bervlcea, 8ytvir.tel Health P.rmit/Services <br /> 16a1 E. Resaltpe Ave.. P 0 BOB 2009, Stockton, t:A 95201 <br /> two AMOUNT DUE AMOUNT'AEMIMI) AR- - /RECEIVED BY DATE PERMIT NO, <br /> . ON no. 110 <br /> T <br /> la.v.rrxu 10. � 1�( 0 • L y s U-16-9v 9b-dx7 �M uw <br />