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APPLICATION FOR PERMIT a` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PMMIT EXPIRES 1_ YEAR FROM DATE Ip„aSD (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 4E4 sl:els Aee Y� /� r^ Cit r`"' C � Lot Size/Acreage r� per^' /^ Q i Owner's Name T C/ WING Li Address��,�:k Jf .o7.15-ey L T Phone/49s: �g� Contractor Addres �� 7 License No. 61 2 w Phone g� '•b /L? J TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out" of Service Well ❑ � PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ � Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK , _ SEWER LINES _ DISPOSAL FL /W'*.PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE'OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f + n industrial ❑ Open Bottom,. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 16441 Pack LYTracy-_- -. - Type of-Casing /4tSD i �Y� Specifications '7 I'1'Public �i } C7 Other/r R<"" .r{ €1,pelta Depth of Grout-Seal �t�0 Type of Grou i I irrigation ,Approx. Depth I-).Eastern Surface Seul installed Alled by l Repair Work Done v y`Type of Pump H.P. f r State Work Done Well Destruction O. Well diameter \� , Sealing Material & Depth 1 +_ , L +` Depth Filler Material 6 Depth a _ r a _ TYPE OF SEPTIC WORK: NEW'INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION'P I (No septic system permitted if`public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial— Other t Number of living units:` Number of bedrooms 3 ~Character of soil to aA' epth of 3 feet: Water table depth SEPTIC TANK P Type/Mfg Capacity No. Compartments PKG�TREATMENT PST, ❑ I i Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE f!' Ll No. & Length of lines Total length/size FILTER BED _ 0 Distance to nearest: Well Foundation Property Line t SEEPAGE PITS 11 DepthSize .y - V y Number SUMPS r LI Distance to nearest: 'Welt Foundation] I Property Line DISPOSAL PONDS p LJ' .v 1 - t l , I hereby certify that I 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 c J f 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 CIN certifies the following: "I certify that in the performance of the work for which this permit'ts issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant �Ical r all req ui ins ctions. Complete drawing on reverse side. Signed r �� i Title: r�� a j Date: .`rte.-,9 r EPARTMENT USE ONLY 1 f I Application Accepted by j f Date j 0 Area 3 �I Pit or Grout Inspection byW Date- Final Inspection by para (9 D Additional Comments:""" Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEp tiY GATE PM MIT'ND. INFO ASH �/ . EH 13-24(REV.tin51 �rr--�� ^' / EH 1420 [ V