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APPLICATION FOR PERMIT r�a� <br /> z SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> .p, ZIT EXPIRES I gEAR VROM DAZE ISSUED <br /> t (Complete in Triplicate) <br /> f Application is hereby made to Sari 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 1$62 and the Rulae and Regulations of San <br /> f Joaquin County Public Health Services. <br /> 1 <br /> Job Address 704 E. Sun' Rd City Stkn Lot Size/Acreage 1/2_-ar_re <br /> Owner's Name Louis Sanguirietti Address salve ^ <br /> Phone 931 <br /> Contractor Address License N3,7] 5 6 0 _Phone ` <br /> „ TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEIVIENTya DESTRUCTION 0 Out of Service Nell 0 <br /> PUMP INSTALLATION LXX SYSTEM REPAIR M OTHER p Monitoring Well C7 <br /> DISTANCE TO NEAREST:"SEPTIC TANK +r�0 SEWER LINES DISPOSAL FLD. PROP. LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_a- ' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rt <br /> 1? Dia. of Well Casing rr <br /> 3CXDomestic/Private X(2 Gravel Pack. Ll Tracy Type of Casing Specifications- ff 1 <br /> M Public EI Other 0 Delta Depth of Grout Seal - 10 0 r, , Type of Grout <br /> CJ IrriOetion Approx, Depth ❑ Eastern Surface Seal Installed by <br /> .Repair Work Done 0 Type of Pump SU H.P. T State Work Done _ S OW <br /> Well Destruction D Well Diameter Sealing Material & Depth p <br /> Depth Filler Material & Depth <br /> :TYPE OF SEPTIC WORK: NEW.INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION IZi INoseptic system permitted it public sewar.is- <br /> available within 200 teat.I <br /> Installation will serve: Residence, Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of*oil to a depth of 3 feet: <br /> Water cable depth t✓' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Cl Method of Disposal <br /> Distance tonearest: Well Foundation Property Line <br /> i rv) I <br /> LEACHING LINE D No. & Length of lines Total length/size ' <br /> FILTER BED CJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth f. Site Number <br /> SUMPS <br /> Ul Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> 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 <br /> rules and regulations of the San Joaquin County k <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 n I <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 I <br /> certifies the foCalif ; "I certif that In the performance of the work for which this permit is issued, I shall employ persons subject to workm_an's_ compense• j <br /> tion laws of ail la.' 11 <br /> The applicant uc or tAr. Ct�i1c_0 <br /> mplete drawing on reverse side. <br /> Signed TItIe:VP Clark Wel I <br /> Date: <br /> r <br /> FO DEP RTMENT USE ONLY J <br /> Application Accepted by <br /> Date Area l <br /> Pit or Grout Inspection by nate y Final Inspection by Data <br /> Additional Comments, <br /> 4L <br /> Applicant - Return all copies to: SAN JOAQUIN d6N,TY PUBLIC HEALTH SERVICES ` <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEO A RECEIVED BY DATE PERMIT�NO. <br /> CK <br /> INFO GASH - <br /> + EH 13.24 UIEV.1/MS1 <br /> EH 1114.70 �-` V3 <br />