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APPLICATION FOR PER9IT <br /> SAN JOAQUIN COUNT" PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 11SAiTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (279) 468-344-73,�/.}v <br /> IT FJ(PrP=E3 1 YFsAR r809 DATESSSUIM <br /> (Complete in Triplicate) <br /> A,aplication is hereby lade to Sats Joaquin County for a perch to construct and/or install the work 'herein described. This <br /> apylication is M14e in CONW11 Mce with 8411 Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Josgtaia w"outy Public Health serviette. !� <br /> Job Address - 521 NORTH +uE (�E 5240 City E_ODI Let Slze/Acreage <br /> � "�� a ACRES <br /> Owner's Na Address 521 N. CHROKEE LAME T I . CA Phone <br /> ALCINN ERGY AND RANCHO CORDOVA _ <br /> Contracts _,9A7A�I! E INC Address �j] <br /> Lic�se'No._5.rj4979_Phone <br /> TYPE OF WELLIf'UMP: NEW WELL Q WELL REPLACEMENT M DESTRUCTION 0 nut or Service Yell <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER�1�p Lupi R�NGStll rty <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PRalr, 7( <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTtNDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r 11 <br /> 11 Industrial 1 Open Bottom 0 Manteca Die.of Well Ekpavali0n '1'r `T <br /> Dia. of Wall Casing <br /> ❑Domeslic/Private , 0 Gravel Pack 0 Tracy 0 Type of Carng_ ham' Sr-6+,G 4�a Specificslione <br /> 0 Public 0T--;rz( 011ier�k,, 0 Delta SOI Depth of Grout Seal `3rt� G? e ,5 <br /> tU to R. r nct� Type of Grout <br /> rJ Irfrualion . { �q AP W1,111. Depth 0 Eallem Surface Seal Installed by ' r<�'� (AJ <br /> Repair Work Done U I T-44 o!Pump H.P. 51014 Work ponce Q1p <br /> Well Destruction 10 Wall Diameter rr(AiirJ' Sealing Material i Depth _Al�GfJ <br /> Depth Tiller Material i Depth t)f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIRIADDITION 0 50ESTRUCTION M INo septic system <br /> permiusd if public tetMr is <br /> available within 200 feet.l <br /> Insteffati0n will nerve; Residence_ Commercial— Other <br /> f_1..)Number of living unite: Number of bedrooms <br /> Character of coif to a depth of 3 feet; taster table depth <br /> TANK Q Type/Mfg Capacity No.Compartments <br /> PKG.TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No.6 Length of lines Total length/site <br /> FILTER BED 1.1 DistInca t0 nearest: Well Foundation Property Lino <br /> E <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS LI Distance to nearest: Well FoundOfon� <br /> DISPOSAL PONDS 0 Property Line <br /> I hereby certify that I hove prepared this application and tha;the work will be done in accordanco with San Joaquin County drdinanna,state laws, and <br /> rules and regulations of the San Joaquin County <br /> KOM#owner 01 licensed agent's signature c@41dies the following:"I cert.fy that,n IAV pertormznce o1 the work for which this permit is imued,I shall not <br /> employ any person in such manner ss 10 become subject to workman',Compensation laws dl Calilpmia,"COn1faClnl's hiring Or ewb•COBtr{Cling trign{tUre <br /> ctMilies the falloWng:"I certify that in the performance of the work for which this permit is 40400,1 shall employ persons subject 10 MrorkrTlgn'I CGmpentp• <br /> lion laws of California." <br /> The applicant must Call for all required inspections.Complete drawing on favorite sii e, <br /> Signet X— Title: <br /> Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate <br /> Area <br /> Pit or Grout Inspaction by Date Fins[Inspection by <br /> Osie <br /> Additional Comments; <br /> licaat - Return ►Il copies to: SAN-JOAQUIN-COUNTY-PUBLIC-HEALTH SERVICES <br /> ENVIRQVNENTAL HEALT3 DIVISION PERWIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STUCgTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMiTTEO CA.t RECEIVED BY DATE INFO PERMIT'NO: - - <br /> IN 13-24 lottv. <br /> TMI <br /> REPRODUCTION .Or THIS - - <br /> DOCt r CANNOT <br /> BE <br /> T TO TSE <br /> �L OOHDLTr�N OF THEE <br /> ORIGINAL <br /> � stn <br />