Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c'd�y <br /> ENVIRONMENTAL HEALTH DIVISION / <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PFaMIT 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 /> y <br /> application is made 1n compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address STADIUM DRIVE & SANGUINETTI LANE City STOCKTON Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor PC EXPLORATION, INC. Address 1780 VERNON ST, ROSEVILLLE License �a 265556 phone 916-783-973 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION Out of Service Well ❑ <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { <br /> 1-1 Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing_ Specifications , <br /> l'1 Public El Other FI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dane _ <br /> Well Destruction ❑ Well Diameter' Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I [No septic system permitted it public sewer is } <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other I <br /> Number of living units: Number of bedrooms <br /> Character of sail 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 Cl No. 8 Length of lines Total lengthisize t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line F"AYMENT <br /> SEEPAGE PITS 11 Depth Size Number 1993 <br /> SUMPS LI Distance to nearest: Well Foundation Property LineSAN f .7 <br /> OISPOSAL PONDS ❑ JOA <br /> QU�N COUNTY <br /> ­ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoENpAt� l and # <br /> rules and regulations of the San Joaquin County ` H DiY1510N j <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 subcontracting 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 Califo <br /> The applicantu all !or all :ti�irctions, Complete drawing on reverse side. <br /> Signed Title: GENERAL MANAGER Date: 8/23/93 F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by "� _ Date Area <br /> I _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> f <br /> f <br /> Additional Comments: 1~ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ^� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED cicw RECEIVED By DATE PERMIT NO. <br /> INFO CASH <br /> ' Ek 13:24 1REV. 5I WD (gyp, va (B D, (� 3&a�3 735 9 23 -l�aZ <br />