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TF APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PRMIT 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 1662 and the Rules and Regulations of San Joaquin County Public HealthSrervices. / Job Address fb�.�'� _ rfJCity Lot Size/Acreage Owner's Name Zamme sol � ddress as. O, t!'[_ Phone X44{ Contractor Address Pr. License N. *.� _ Phone /� !i 7 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERJ` Ot itoring+�Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LI f E FOUNDATION AGRICULTURE: WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f +s,dfy-e.&Y Gprf►tQ D industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private Gravel Pack M Tracy Type of Casing _ Specifications III Publicther Ll Delta Depth of Grout Seal Type of Grout I I Irh9ati n Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. S to ork pone Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material tr Depth �i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 300 feet.) L/1 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-I No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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 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 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 required inspections. Complete drawing on reverse side, Signed Title: �41z2Date: FOR DEPARTMENT USE ONLY �} Application Accepted by t Date t;� ` Area Pit or Grout Inspection by cpm Date Final Inspection by 017. Date J f� Additional Comments: �[ F r ! bo FI 4Dm LJ Applicant - Return all copies to: San Joaquin Coun y Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 41 RECEIVED BY DATE PERMIT'NO. q Q /� , . EN 13.24 IREV.r,n 61 EH t4-2a T�v a 1[ 1 91-3 77