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SR0081473
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4200/4300 - Liquid Waste/Water Well Permits
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SR0081473
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Entry Properties
Last modified
3/16/2020 4:52:30 PM
Creation date
3/16/2020 2:02:46 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
FileName_PostFix
SSNL
RECORD_ID
SR0081473
PE
2602
STREET_NUMBER
11065
Direction
N
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
Zip
95212
APN
06304023
ENTERED_DATE
11/26/2019 12:00:00 AM
SITE_LOCATION
11065 N ALPINE RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
TSok
Tags
EHD - Public
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FOR OFFICE USE: APPLICATION FOR WELL OR PlitSi FF.RMIT PERMIT N0. <br /> -7z--1 3 <br /> (Complete in Triplicate) Date Issued: 3-/.5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: ll 0St�<<r_�oti <br /> CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: T <br /> CONTRACT 'S AME: EaCENSE 4l Z.55977 PHONE: q.> <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /': PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> Co <br /> N <br /> Z <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> .O <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE 1 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: A CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �� DATE: S �y <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: Z!�z— DATE ?-;7-,7 7i <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />
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