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_ pPLIC.mTf1V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I Z�NVIRONM.BNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT SIRES 1 YEAR FROM DATE ISSUED <br /> (ComDiete in Tripiicate) <br /> to <br /> struct <br /> ndl or <br /> tall <br /> work <br /> in <br /> Application is nereby made to San county 'cr a pnaacenNO. 549gand i862sand theeRules andeRegulationadoY Sates <br /> application is made in ca*liance with San Joaquin Countyy Ordird <br /> ,;oaquin ::ouoty Public Health servicer. <br /> :tib Address <br /> Dividend Development Cor oration zity Trac_y Lot SizeiAcreage <br /> Southern Pacific .1 Phone <br /> Qwnar's Name Trans artation Co. address San Frais <br /> n <br /> 11101 I&ite Rock Road - <br /> Contractor McLaren Hart =ddress <br /> Rancho Cordova, CA License.No.505932 <br /> hone 916 6 <br /> TYPE OF WELL/PUMP' NEW WELL C WELL REPLACEMENT C� DESTRUCTION G Out �o Service well <br /> Well <br /> PUMP INSTALLATION C � <br /> SYSTEM REPAIR 0 OTHER G <br /> DISTANCE TO NEAREST: SEPTIC TANK 71000r�- SEWER LINES 7 1004 DISPOSAL FLD.`LIQQO[PROP. LINE 2.��- t <br /> FOUNDATION 71000 r AGRICULTURE WELL71000 0 VPLL30-100 PITS15L1MPS7-,.Q00 <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �— inches Dia. of Well Casing <br /> industrial G Open Bottom � Manteca pia. of Well E><cava[to SCH-40 <br /> 1k7 Type of Casing PVC Specifications <br /> Domest+clPrivate Gravel Pack Tracy 3,5-13 feet Type of Gro utcement/bentot� <br /> -1 Other Delta Depth of Grout Seal <br /> " Public � Gre Drilling 11 <br /> IrriOatwn 10-20'ppra Depth I I Eastern Surface Seat lnsulied by <br /> P State Work Done_ W <br /> :aepair Work Done U Type of Pump,��— Sealing Material i Depth. <br /> Wail Destruction C Well Diameter <br /> Depth I Piller Material i Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DES TRUCTION I I a�ailahlarw within 2D0 feetc system �t�d pubkc se"",I <br /> Installation will serve: Residence Commercisl, Other <br /> Number of living unify: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ TypelMtg <br /> Capacity No. Compartments <br />+ <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ 1 <br /> Distance"to nearest: Well Foundation Property line <br /> Total lengthlsize <br /> LEACHING LINE CI No. & Length of linea Property Lina <br /> FILTER BED 0 Distance to nearest. Well Foundation './ <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Distance to noorest: Wad Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> rk will be dons in accordance with San Joaquin county ordinances,state laws. and <br /> I hereby certtty that I have prepay this application and that the wo <br /> rules and regulations of the San Joaquin CountT <br /> Homs owner or licensed agent's signature candies the foliowmg; � I comfy that in trio performance of the work for which this permit is issued. i shad 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 /> cartifies the following. 11 termly that in rhe performance of the work for which this permit is issued,I shall ampjOy persona suoiect to workmen's compenss-- <br /> lion laws of Califomia." <br /> a The appli nt must tali for sit required inspections. Compete drawing on reverse side. / <br /> lei <br /> Signed X Title: <br /> s tS f P C�0Sc l Pn'177s ate: A 11 <br /> FOR DEPARTMENT USE ONLY �? <br /> 1 <br /> Date �Z_ Area <br /> #2q <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date 9�Finsf <br /> inspection by Dau <br /> Additional Comments: 6U, idd5T3i� <br /> Applicant - Return all copies to: San Joaquin county Public Health Services. <br /> 1 Environmental Health Permit/Sere es <br /> 445 N San Joaquin, P O Box 200 , tkn, CA 95201 <br /> FE AMOUNT DUE AMOUNT REMITTED M ED 6Y DATE PERMIT NO. <br /> { INFO - Z�� f <br /> !1, H S9•�ta 7,� 273x31 ' 8 I �2 <br /> Eli 14.29 - - <br />