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APPLICATION FOR PERMIT SAN JO,..JIN COUNTY PUBLIC HEALTH SLICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address R90/ S, LDtaSE Aye5" City LAT-If 120 P Lot Size/Acreage f R 533v Owner's Name HAWircA tw,F(t:D CCH,DISlddress S LD41s6 LI'��t(ZA Phons(.24 Contractor SP�-r•�Me0�� dress E • Yeng. S1bCkTD/License No. 5 (09 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)9, Mocn�iitoring We115� DISTANCE TO NEAREST: SEPTIC TANK PJ A SEWER LINES > 2S� DISPOSAL FLO.�_ PROP L Ne .503 FOUNDATION j O r AGRICULTURE WELL _f^(A OTHER WELL L PITS/SUMPS ZO" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 0 Industrial O Open Bottom Manteca Dia. of Well Excavation 7 ' Dia. of Well Casing )d Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ P Y'G Specifications `} SO I'1 Public V4 other MoKif-crl n Delta Depth of Grout Seal "Z/ Type of Grout I I Irrigation -A?Approx. Depth Eastern Surface Soul Installed by 9P6CrRA-C M C—"L QR-*r(O K WC, Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of 500 to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, 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 in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature candies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The appt call for all required inspections. Complete drawing on rev res side. applicant C� Signed Title: _ Date: -DEP RTMENT USE ONLY Application Accepted y Date `�'�" grga�0 1 Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A OUNT REMITTED CK RECEIVED DY DATE PERMIT'NO. INFO CASH 134s� E- ID-3-R`( o�t3