Laserfiche WebLink
I� APPLICATION FOR PERMIT <br /> l Y' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1 YEAR FRAM DATE ISSUED <br /> (Complete in Triplicate) <br /> 0 <br /> Application is hereby made.to .San Joaquin County for a permit to coratruct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1 63 and the Rules and Regulations of San <br /> Job Address D/4/lt/ oR, ys7.LJ/!a AREESr7 NVIC City /10DfJf7ZI? Lot Size/Acreage <br /> Owner's Name PG&E Address POBox 930 S Phone - <br /> Contractor General _Const._ Address q056 E. HWV 120 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL CA WELL REPLACEMENT © OESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 Cyt Monitor'ng Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 14 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f! IndustrialO[�ottom ❑ Mat♦teca Dia. of Well Excavation Dia. of Well Casing <br /> EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public [y-I�Oth r ( Delta Depth of Grout Seal 87i Type of Grout g sack mix <br /> 'WW."V Well , Ozprox. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Donr: 0 Type of Pump H.P. t Worl�Qone_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth 1�Wre l.0 <br /> Depth Filler Materiel 8 Depth o e Breeze <br /> �SEPTIC RK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo s=permixiedifublic seweavailaInstalResidence— Commercial Otherr <br /> Number of livng units: umber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> [� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well anon Property Line i <br /> LEACHING LINE C1 No. & Length of lines ength/size <br /> FILTER BED 11Distance to st: Well Foundation Pro Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> AL PONDS ❑ <br /> I <br /> I hereby certify that I have 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 <br /> Home owner or licensed agent's signatura 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 laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing: "t certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust Il for all r aired 1 petitions. Complete drawing on reverse side. <br /> Signed Title: Engineer - Estimator Date: 4-20.90 <br /> R DEPARTMENT USE ONLY ^� <br /> Application Accepted by Dais rea ` <br /> ?it oGro, napection b ate Final Inspection by / Date <br /> Additional Comments. � � ��r� 3` di-JZ _,.. ........ ....._. ' <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2W9,-Stockton, CA 95201 <br /> INFO <br /> FEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> • EH 134MEV.1i�a� 2E /A <br /> FH:x.7,5 (. � � Q lQ <br />