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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> _Sd ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 ,2 <br /> (209) 468-3447 <br /> EXPIRES 1 YEAR <br /> (Complete in Triplicate) <br /> Application is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 6588 Wer-t• Zae.Obs 'ROA A City_561:.k4W __ Lot Size/Acreage 50" X SO <br /> Owner's Name <br /> Larry Pe.1legf ( Address 6S8.15.__ ga+ S0.CA6S �d Phon 413-707 <br /> l <br /> Contractor,lL�rnc.�'fit[d/��a,�w�, Iw Address 1)n A 4-- i-.r1L 4ALicense No. Phone / <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER )< Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK �!�` SEWER LINES , ! !AD' DISPOSAL FLD.)_ PROP. LINE 49OZ <br /> FOUNDATION 50z AGRICULTURE WELL JI►a- OTHER WELL7loo' PITS/SUMPS W6 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L Dia. of Well Casing A► <br /> U Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing 141p► Specifications wilk <br /> M Public Pf Other S L 3ORWA6 Delta Depth of Grout Seal &NT1kV, VType of Grout WSA*t GfioMlis7ilT <br /> r <br /> G Irrigation �10�1194$,`_„Approx. Depth 11 Eastern Surface Seal Installed by W/A <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> F SEPTIC WORK: NEWINSTALLATION O REPAIR/ADDITION C1 DESTRUCTION G lNo septic system permitted it public sew A <br /> available within 200 feet.) (� <br /> Installation will Residence..._.. Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: at table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well ation Property Line <br /> LEACHING LINE Cl Na. 8 Length of fines �ngth/size_FILTER BED 0 Distance to sC. Well Foundation ' <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> D ALPONDS 0 <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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 compenso- �\J <br /> tlon laws of California." <br /> The applicant ca r to rad inspections. Complete drawing on reverse side. <br /> Signed g Title: _.�f.%,�r� R,•..a _ Date: �,T—G•'�/�• . ,•.,..__� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted byData�__x! G Area � �(,_,_ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> I <br /> Additional Comments: <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMII'NO. <br /> EH 13.24[REV, n s) �� `"� t0? <br />