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ADPL I Ca t 'OP PERK I T
<br /> SAN JO,A,QUIN COUM PUBLIC HEALTH SERVICES
<br /> EN V I R ON'ILMAL HEALTH DIVISION
<br /> 1601 H. BAZKLTON AVE. . PHONE (209)468-3420 9
<br /> ap 40 BOX 2009, STDCKTON. CA 85201
<br /> E%PIRES 1 „TUg ER08 DATE _ .Sr�EiID
<br /> (Complete in Triplicate)
<br /> ApplIcs•_Son 1a l,ereb. rade ',.a SL Jaequic County for a permit to constmict wnd!or Soet:all the Mork herein 6escribec'. T.1s
<br /> ss�li[&..aD I e CO �i�,re vi:! 6nn J
<br /> .;aa;uin Cour:Z ft.t!',c Hca1tL Services. °G''"::' Cc,=V Ord:irs,oce 11>. 5" ane 166_ Lrtd the Rule& ant Reg",A Ione of 6a-.
<br /> Job Addtest t City E s c a 1 on Lot Sise!A:reage 55 acs .
<br /> Owner's Narne 4c 1.1 i e r Farms Addt!ss 71750 E. River Read Esc a l o n Phone A-3-8 f-2 5 14
<br /> Con;rattoi 9APt4t'k C!tiSTRU TjN Aijdress 7900_WREN RD. Oakdal19,,,,_License NaA-B 44- fS6 Phone47- 480
<br /> 7T,[7g. 'v ':LLIPLIMP NES" WELL E Vi1Ei� REPLACEMENT 7, DESTRJCTION C Out of Service Yell CI
<br /> PUMP INS7ALLA.TiDN C, SYSTEM REPAIF a OTHER i_ Wor.itoriag hell
<br /> G ST-p w NEAREST: SEPT-". 7ANK SEWER LWEs DISPOSAL FLO. PROP. LINE
<br /> FOUNu&TION AGrr.C'rcT'r RE WELL OTHEP WELL PITS,'SUMPS
<br /> [;SE TYPE OF WELL PROF:EV. AREA CANS' LICTICt'. SPFC{FICATrDNS
<br /> Ir: i:st•gP.+ �: Dfw' r!ottom C Mar,leca Of& o' dVell ExzavatioR Dia of Well Casing
<br /> pr�re S!,C.'Pr,vete L Gr r(. Pack C-j Tracy Type c' Casin rfi i n
<br /> � Ptrbil�. -� O g Spec G8',D S
<br /> i aver � De!! Depth of Grow Sea! Type of Grout t
<br /> Ir"ilar'on APnrcr Dep"', I ! Easiern
<br /> Surface Sed! Irtstallbd D`-
<br /> Repa,r Work Done Lj Type c.' Pump H F. State short. Done_
<br /> We!` DestruC60rt G Weli Dia-ne!er Sea:i.ill; haterial l Depti:
<br /> _ DeCrh Filler lrsterial i Dept: v�
<br /> k TYPE OF SE.Plic IMORK NEW INSTALLATION ; I 14EP;-Ik,ADDIION)K*xDES7RL)CTION i iNo r:eC,rrc system peau,"tad it public sewer is
<br /> mailable within.200 feet.]
<br /> fns;atlalio: will rr.ve Res;dence Y Cornmercikl_ Other
<br /> Number of iivm units a'
<br />. !d' ..] NurnDe, of �edrDOmi 1 ,,
<br /> Chart;ter at moi+ to a 6e;s1 of I feel s d n d y Water table depth
<br /> SEP-IC Tk.r,!K Ty::*'Mig Anthony $ son concret[typac'zr 1500 No. Cortspartrnrrnts
<br /> PK TREATMENT r. Method of pesposai
<br /> Dista-ace to nearest: Wel" Fau*rdation Propene Line
<br /> i
<br /> LEA,Ct• iNC ONE Ix Na. b Lrngth o' sires 7 � I00 ft . Iola.' Iengit,!we 400 sq. ft .
<br /> FfLTER BED ❑ Distance tc rt.",051: Wellr.
<br /> 500 ' Foundatien 50' Propert>,� Lire �r.�03L
<br /> SEEPAG£ PsTS 1 1 Depth Size Number 1 +
<br /> SUKA.CIS LI Distance to rwmrest: Well
<br /> - Foundation Property Line
<br /> DISPCSt.I PDKID S G
<br /> 1 here:,, Cer?�(� t!LF; i t:8ve 9>ieLa'0; this ant;t'�atio- and Stat ttvE woo xdi be OOr* rn accorGel4E
<br /> t"IDrt'Ta try h San Joaquin
<br /> ;.pu [} Odnces. state ( ti , an►ues encthe 5e;ti .tt$;�in Court, 9
<br /> oWne+ µ 9 'elure ce^.fyS
<br /> �
<br /> 'be f01101-ir,R '•I crtty that in the p6yor•Ysa'lce of the wo,k for Which this permit is Issued, I "!' not
<br /> err,Pi,a1•any i}=inti in svcl rhist 'tr_, a5 to barn-*aub)ect IC w;,-k*nB-.'&tprnMnsai�:.r taws 0� Caiilornia —Contractor's luring or Sub-contract rng tiignalwv
<br /> eerrrfres the fosow,r g. -j ci�r-ofr that in the performance of The worts fp*wNch this perm,;is is&ued. !aha''employ pefsons subject to workman's compensa
<br /> tier, ia+tic of Ga+tnrnia,"
<br /> The app:ccs;-1 " zt ui: fog it; r es,red insoets+ons Carnptete Mswrnjron revorw side h
<br /> Signe 1
<br /> Trete. Date: �
<br /> fq&DEPARTMENT USE ONLY GG
<br /> Apps.at,on Accosted by Date
<br /> Pit tv Grout irr:0171::. ; by Date Fina' Ins Date__Le
<br /> Add trona' Com-npnts
<br /> APx3.1ar: t Lis eaylo& Lo: Sar Joa{lit Cou,'r R::Sc
<br /> Se-vices, b;YironmettiC flea:tt Pera:t!Serviceo
<br /> E&seltx Ave., P O Sox My , >:to:k c:., CA 952:.1
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