Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 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 in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 3830 E. Woodbridge Rd., Acampo, CA City Lot Size/Acreage 22 acres bare <br /> owner's Name Joe Gotelli & Sons Address 9392 N. Hildreth Lane, StocktonPhone <br /> Contractor Purviance Driller,InC Address P.O. Box 64,Linden License No. 377923 Phone 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL Jl WELL REPLACEMENT F1 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION X1 SYSTEM REPAIR 0 OTHER O Monitoring Well 0 <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 /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing /a � <br /> C1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications—v��d' <br /> I'1 Public Cl Other F1 Delta Depth of Grout Seal 1 Ty <br /> p of rout 9 <br /> / R <br /> iKl Irrigation f <br /> 7 '—% Approx. Depth 1 I Eastern Surface Seal Installed <br /> Repair Work Done 0 Type of Pump 'TviIS H.P. -2V State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material 4 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I INo 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method yniAi�p <br /> Distance to nearest: Well Foundation Property Lir T _._ . <br /> RECEIVFD <br /> LEACHING LINE L1 No. & Length of lines Total length/size MAR 1 8 1994 <br /> FILTER BED 0 Distance to nearest: Well Foundation Prope� na-. — <br /> COUNTY <br /> SEEPAGE PITS 11 Depth Size Numbs£ JV �g <br /> SUMPS LI Distance to nearest: Well Foundation ION <br /> Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> Thea st call fors r inspections. Complete drawing on reverse sr <br /> Signed,X Title: -� Date: / <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by Date 1 <br /> _ <br /> Pit r Grout spection by etc c- Date - Final Inspe ion by ate <br /> Additional Comments: -CLA < ,v Y,- -I"12- -/7e <br /> Applicant - Return all copies to: San Joaquin Country Public Health Services p o J <br /> Environmental Health Permit/Services (47,90 5 P.00 •� y q a a S <br /> �0 z/� <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA $601 <br /> Eli <br /> T DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. <br /> EHtJ.2/IREV.tinsr ti 13 q, L� I-�� j !1 hS ( �f �/!7 <br />