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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� t ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, 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 9189 N Ashley Lane City Stockton Lot size/Acreage 45acres Owner's Name Joe GOtelli & Son Address 9189 N AShleV Lane,STockton Phone ContractorPuryianee DrillerS,In(Address P O Box 64,Linden License No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION N Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private Cl Gravel Pack*, O Tracy Type of Casing_ Specifications I'I Public El Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Err Sealing Material & Depth r 6cack sand & GQ919nt pumped QQ Depth 135' Filler Material & Depth frrxn hnttnm lip (\ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION.'( I DESTRUCTION I I INo 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 a Capacity No. Compartments PKG. TREATMENT PLT.❑ �— Method of Disposal Distance to neargst: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la 'fornla." The applicant us call fo all r it d inspections. Complete drawing on reverse side. ' Title: Corporate Secretary Signe Date: 4/26/93 G !: FOR DEPARTMENT USE ONLY Application Accepted byA�lDate Area o2_ 11 s Pit or Grout Inspection by Date Final Inspection by Date` Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE(INFO AMOUNT DUE AM/OUNT REMITTED CK 0 CASH RECEIVED BY r/ DATE PERMIT'N0. �/J} . EH 13.24IREV.r�N51 /jJ'>\ r L� D� �0 7 / EH 111.26 mow.•.. ) tttvvv 9