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APPLICATION FOR PERMIT � y w>� . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIR1(' ALTH DIVISION 1601 E. HAZEDF AVE.TAL , PHONE (209)468-3420 i P 0 BOX 2009, STOCSTON, CA 95201 J!ERM T -EX?IRES 1 YEAR '.FROM DATR ISSiI (Complete in Triplicate )N Application 1e hereby made•to San Joaquin County for a permit to construct andJor tl vpprk e yescibed. This application is meds in compliance frith San Joaquin County Ordlnsace•No. 549 and 1$� RAq? end ' ons of San Joaquin County Public Health Services. RjjjJTC�i�� '�°�1 Jab Address r City Siz-,1cirn Lot�3� �r -3•tl-'. 40$.' Owner's Name Ley" QLS A. Tae. _ Address � � Phoha N 135`- Contractor Address 416 s Sf [e-Zj License No. f7YC.,SI47 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION,E] SYSTEM REPAIR ❑ OTHEf? ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD• PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Sdc- aH-aLk-d * Industrial Cl Open Bottom ❑ Manteca pia. of Well"Excavation ic) Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 41, NO. Specifications I'] Public Other 'AoAi A;, t"1 Delta Depth of,Grout Seat "'�1 Type of Grout tid F eeiPurrf' I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by. rCxCCI�-cct� __ Repair Work Done ' ❑ Type of Pump H.P. A State Work Done Well Destruction ❑ Well Diameter Sealing Material &"Depth Depth Filler Material'& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer isIle -V available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth C% SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINEA 0 No. & Length of linea' Total length/size FILTER BED ❑ Distance to nearest: .. Well Foundation Property Line SEEPAGE PITS AI;A I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 certifies the following: "I 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 applicant must call for all rq,1�/ired ins>p�ections. Complete drawing on reverse side. Signed Title• � , L7�` Date: - � . FOR DEPARTMENT:USE ONLY r/ Application Accepted by Date Tom[ . �,l Area Pit or Grout inspection by Date Z t I Final Inspection by `y l l"- " DatO Additional Comments. _ '!� �L""C 41eku 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 INFO AMOUNT D AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO, . EH 17.24lREV. /�-