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APPLICATION FOR PERMIT V\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 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 9130 N. Ashley City S t k n Lot Size/Acreage 27 Owner's Name Ray S a n g u i n e t t i Address same Phone 931-2152 Contractor_ lark We 1 1 Address 917194 F Ch n r t P r License No. 3.31-_9-6-Q—Phone 4 6 9- TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTXRIX DESTRUCTIORt-I Out of Service Well Q PUMP INSTALLATION)a SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.+1 00 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial J)XOpen Bottom ❑ Manteca Dia. of Well Excavation 16 3 /4' Dia. of Well Casing 1 CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing c, i Specifications . fl O> er n Delta Depth of Grout Seal 50 Type of Grout 9 S a e 1 RXlxl dirigation 3 .Approx. Depth I I Eastern Surface Seal Installed by ('.I n-k epair-Work-Done U Type of Pump S is h H.P. *10 State Work Done_ i n.-t a 1 1 Well Destruction O Well Diameter 1 Lr" Sealing Material & Depth 1- Depth I I n ' Filler Material & Depth n to 100 „e a r ••21 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No 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 soil 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 Cl No. & 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 ❑ 1 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 certif hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C Zpa."The applica all I d i I omplete drawing on reverse side. Signed X�10 Title: V P C I a r k W P I I Date: 27 .Tan A'I F R DEPARTMENT USE ONLY q Application Accepted by % Date 1 -�� ` Area 0 Pit or Grou Inspection b/y�/ Date= � Final Inspection by Date 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 I CK RECEIVED BY DATE PERMIT'NO. INFO CASH Q q . EH 1t1-28 3-24 IREV.1"51 W 9- ftl it tLIDV�� ( 7 • 3 H /D