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ADPLIC4m*n-: SAN .IO r1UIN COUNTY PUBLIC HEALTH S*VICES ENVIRONMENTAL IIEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coa:pliance with San Josquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address `1.233 (,rand Canal Blvd. City StAcktgn Lot Size/Acreage Owners Name Po Ying Chern Address C/o Triad Pacific Management Phone 275 Lee Road, Suite C T/N1 Tyke,-- ,SCA Contractor B and F Drilling Address Watsonville, CA 95076 License No. 519428 Phone (408)722-31 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION ❑ Out of Ser e1 PUMP INSTALLATION C SYSTEM REPAIR L) OTHERNMonitoring Well (� est Boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I PNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i.l Indusinal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l� N Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public 1.1 Other fl Delta Depth of Grout Seal Type of Grout , i Irtigavon _Approx. Depth I I Eastern Surface Soul Installed by Reoeir Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Waif Diameter Sealing Material i Depth 11 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I ! DESTRUCTION 1 I (No septic System permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of nail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypsrMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ci No. 6 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line \ SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line \ DISPOSAL PONDS ❑ I hereby cenefy that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordinance$, state laws. and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: ''I certify that in the performance of the work for which this permit is issued. I shall not employ any person.n such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies the following: "1 certify that 1n the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of C"'Or iar� The applica m t call for all r cared in Ons. Complete drawing on reverse side. �� Signe X Title: Date: 1L��%Sf FOR DEPARTMENT USE ONLY Application Accepted by Date Z AArea Pit or Grout Inspection by Date Final Inspection by Date �ddmcnal Comments: '•apllcant - Return all copies to: San Joaquin County Public Ilealth Services Environmental Ifealth Permit/Services / 445 N San Joaquin, P O SON 2009, Stich, CA 95201FEE INFO AMOUNT CUE AMOUNT REMITTED CASH RECEIVED By OATE PERMIT NO. EH 1324 IREV EH 14.21