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1DpT.j(r`.manv <br /> ria✓ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 P <br /> P O.--BOX 2009, STOCKTON, CA 95201 (OY <br /> PERMIT ....SPIRES 1 YEAR FROM DATE ISSUED <br /> (Compiete in Tripiicate) <br /> .application is hereby made to San Joaquin County for a permit to construct andior install the work herein described. This <br /> application is made in compliance vith Sag Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> In County Public Health Services. <br /> Job Address Dividend Development Corporation __ C;ty Tract/ Lot Size/Acreage SnDrox_ 100 An es <br /> owner's Name Dividend Dev. Corp. Address 3600 rruneridge Ave. .Santa Clara one <br /> Rancho Cordova, CA <br /> Contractor i:cLaren/'Fart :,dress11101 White nock !load, L,cense N0.505932 Phone(916) 638-3616 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C, DESTRUCTION i=, Out of Service well C3 <br /> PUMP INSTALLATION C SYSTEM REPAIR C, OTHER G Monitoring Well C5 <br /> OISTANCE TO NEAREST: SEPTIC TANK p' 1000' SEWER LINES 7 1000 OISPOSAL FI D�y 1 nnn I PROP. LINE ?a' <br /> r ori o 30-10p' 1000' <br /> FOUNDATION 71000 AGRICULTURE WELL7�QQ OTHER WELL PITS/SUMPS 7 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrut 0 Open Bottom C Manteca Dia. of WON Excavat n e o inces pia. of Well Ca <br /> Domestic/Private M Gravel Pack r, Tracv Type of Casing PV Somucattons <br /> 3.5 meet cement/bento»Iit <br /> Grocer �a <br /> regi Drilling and T a in <br /> , Irrigation 15 Approx. Depth I I Eastern Surface Seal Installed b� g <br /> Repair Work Done . Type of Pump H.P. State Work Done <br /> Well Destruction O WON Diameter Sealing Material i Depth <br /> Depth Filler Materlsl i Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system ownutt"J public sewer is <br /> ivarlable within 200 feet.) <br /> Installation will serve: Residence_ Cpmmwetaf._ Other C <br /> Number of living units Number of bedrooms �- <br /> Character of ser to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartmrnts <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to newest: Well Foundation Property Line C <br /> t �- <br /> LEACHING LINE O No.i Length of unes Total lengtWsizo Z <br /> FILTER BED O Distance to nearest: Well Founostton Property Line I G <br /> , <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to newest: well ' Foundation Property Line <br /> OISPOSAL PONDS ri <br /> hOeby ceRdY that 1 have prepared this application and that the work WIN be done in accordance wan San Joaquin county ordinances. 81818 laws. Ano <br /> rules and regulations of the San Joaquin County <br /> Home owner or licanit"agent's signature certifies the following: "I Candy that in tel performance of the work for which this permit is issued. I shelf not <br /> employ any person in such manner 88 to bwCOnte subleet to workman's compensation laws of California." Contractor's humg or sutst:ontreeting signature <br /> candies the foYowtrtg:"I cwW that in tel performance of the work for wntch this permit is issued.1 shall employ persons subject to wornmen's compensa- <br /> tion laws of Calillorrw..• <br /> The applKa must call for 89 required in !se wns. Compete drawing on reverse awe. <br /> Signed — Title: s.;p ery lS l�� CPor c_1 e4447s7LDats• <br /> J FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4�� Date " Area <br /> Pit or Grout inspection by Date Final Inspeetton by Date <br /> Additional Comments: k4a ;?2-I I <br /> Z1t 2-0 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin. P O Box 2009 tkn. CA 95201 ll <br /> FEE AMOUNT DUE AMOUNT REMITTEO s RE 0 OY DATE PERMIT NO. <br /> INFO <br /> iFq 3-24I11EV.,,�,�'�JV �•(%U �9.� (Z��o3 j - ---- ..- _8!2-�r� ;q2- ZS <br />