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APPLICATION FOR PERMIT <br /> V\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made 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 9130 N. Ashley City S t k n Lot Size/Acreage 27 <br /> Owner's Name Ray S a n g u i n e t t i Address same Phone 931-2152 <br /> 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- <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTXRIX DESTRUCTIORt-I Out of Service Well Q <br /> PUMP INSTALLATION)a SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.+1 00 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial J)XOpen Bottom ❑ Manteca Dia. of Well Excavation 16 3 /4' Dia. of Well Casing 1 <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing c, i Specifications . <br /> fl O> er n Delta Depth of Grout Seal 50 Type of Grout 9 S a e 1 <br /> RXlxl dirigation 3 .Approx. Depth I I Eastern Surface Seal Installed by ('.I n-k <br /> epair-Work-Done U Type of Pump S is h H.P. *10 State Work Done_ i n.-t a 1 1 <br /> Well Destruction O Well Diameter 1 Lr" Sealing Material & Depth 1- <br /> Depth I I n ' Filler Material & Depth n to 100 „e a r ••21 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <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 certif hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C Zpa."The applica all I d i I omplete drawing on reverse side. <br /> Signed X�10 Title: V P C I a r k W P I I Date: 27 .Tan A'I <br /> F R DEPARTMENT USE ONLY q <br /> Application Accepted by % Date 1 -�� ` Area 0 <br /> Pit or Grou Inspection b/y�/ Date= � Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH Q q <br /> . EH 1t1-28 3-24 IREV.1"51 W 9- ftl it <br /> tLIDV�� ( 7 • 3 <br /> H /D <br />