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91-2895
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4200/4300 - Liquid Waste/Water Well Permits
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91-2895
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Entry Properties
Last modified
3/23/2020 10:06:42 PM
Creation date
3/20/2018 10:27:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-2895
PE
4221
STREET_NUMBER
15
Direction
S
STREET_NAME
ADELBERT
City
STOCKTON
SITE_LOCATION
15 S ADELBERT STOCKTON
RECEIVED_DATE
11/8/1991
P_LOCATION
DARRELL V ROBERTS
Supplemental fields
FilePath
\MIGRATIONS\A\ADELBERT\15\91-2895.PDF
QuestysFileName
91-2895
QuestysRecordID
1631094
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> tye1 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> \� P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I `�- <br /> Job Address 15- 5 " /��Qj•--1.L?= e- City l Lot Size/Acreage � 2'3 <br /> Owner's Name ar�� 1 V•' '�� ddress / S ' � ` Phone q "-7 -7 <br /> Contractor S e l Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I/1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ak� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'l Public EI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I 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 applicj t must call for all required inspections. Co�drawing on reverse side. Q <br /> Signed X_,, 9Za4 Title: ��1a9 11 e. C- Date: — 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by��r "00" -c Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date - <br /> Additional Comments: _ /,i re["y—d f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> . EM 13.2 (REV.1/9 51 G�� 7 /1 G?G? /T�' [, a� /►��� <br />
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