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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONKENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P U BOIL 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 XBAR FROI[ BATE ISSUED (Complete in TripliCate) r Application is hereby wade to San Joaquin County for a permit to construct and/or install the work herein described. This application is lade in compliance vlth Ban Joaqulo County Ordinnnes No. 549 end 1952 and the Rules Lad Regulatlons of Ban Joaquin County Public Health Services. Job Addran 747 eou Y L h W: Size/Acre a too- B. 433 4 Owner's Noma EVYWJ COAIQAAy_ S• Address f `ui4`+}, IX IN110-4306 Phone(713)6$G- 1S 3'1.33 JC42,[relr4 94 / y S Contraclor(LS -194Af rl1I4ry Address_Rpul1.r r.'d.yx-_CL 670 T�!� Rf( _ License No.��_.Phone( TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑C.ut Of Serviea Yeti Cl MOnLtoring VellS rf PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � SR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PT4P. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PSTSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑Open Bottom 0 Manteca ";a.al Well Excavation Dia of Wap Cat :. CI Domestic/Private Pt Gravel Pack ❑Tracy Typo of Caainp� Arc Specifications�L u14 0 r y°, I'I Public I)Other Cl Delta Depth of Grout Sul !30 Typa of "19 i,i �t�., - I I irrlgatwn 50 Appox, Depth I I Eastern Surface Seal Instshad by Tren,i is,'bta4+.+r ". Repair Work Done U Typa of Pump H.P. State Work Oona Well Daatruction ❑ Wall Diameter Sealing Mat47riel i Depth L1 Tiller Material S Depth Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permilfed it public{ewer is available wilhin 200 feet.1 jIratallr tion will serve: Residence— Commercial_ Other "�. Number of living units:_ Number of bedrooms - - - f Character of sole to it depth of 2 feat: Water table depth SEPTIC TANK 0 Typo/Mfg CapaclTy No.Compartments PKG.TREATMENT PLT,CI Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE Cl No.&Length of lines Total length/shin FILTER BED 0 Distance to nderest: Wall Foundation Property Lira �i SEEPAGE PITS i i Depth Sin Number `j. SUMPS LI Distance to tlesnat: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ora uncea,elate laws,and ;.I rules and reguationa of the Sin Joaquin County Homo nanny or licensed igenf'a signature certifies tM following:"I cenlfy that In the performance of the work for which thin}permit Is issued,I Mall not y, employ any parson in such rnennar ae to become subject to workmen'&compensation laws of California."Contractor's hiring at sub•conlractlng signature certifies the following:"I Certify that in the perforrnenee Of the work for which this permit is lesued,I sh&II employ persons subplot to workman's compensa• N. Ilan laws of California," r The epplicmnt it/u9 for MI r ukaddl/nipictions.Complete drawing on raw/r'w sac/da. ,a Signed ILA�ile tiei!/tr Title: U['/ tf� — Datr /`f! r•Ii OAA r-1/I/ ! �.. a,. /.� OR DEPARTMENT USE ONLY Y Application Accepted by Date Area Pit or Grout Inspection by Date 1' Final inspection by Dau Addlilonal Comme+te; Applicant - Return all copies tat Baa Joaquin County Public Health Q Services, Eavlronsiantal Health Permit/Bervices 1601 1. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CK I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED ev DATEINFO PFRMIT'NO. .Im1174 IREV. eat 14.A 1 15-22