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_ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY' PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 '{ (209) 468-3447 R t (Complete in Triplicate) Application ie hereby made to sin Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in coupilance with San Joaquin County Ordinance No. 5h9 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. 11704 E. Sun Rd Stkn Job Address City Lot Size/Acreage 1 �2 acre Louis Sanguinetti4 salve Owner's Name Address Phone 931 -2799 Contractor Clark Well, Inc Address 2024 E. Charter W License No.371 560 Phone TYPE OF WELL/PUMP: 7r- NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTIO Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation I Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other p Delta Depth of Grout Seal Type fi Grout CI Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by l Repair Work Done 0 Type of Pump H p —i;--- Stats Work Done Well Destruction ❑ Wall Diameter 6 Sealing Material i Depth �3 1 f i I I Depth 130 + Filler Material i Depth to top 6 sa k TYPE OF SEPTIC WORK; NEW'INSTALLATION L'l REPAIR/ADDITION M DESTRUCTION G {No septic system permitted it public sewer is Instillation will serve; Residence� Commercial_.,_ Other available within 200 feet.) ' Number Of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK- p T ! Water table depth Type/Mfg CapacitY— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation ' DISPOSAL PONDS E) Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, $tate laws, and rules and regulations of the San Joaquin County Home owner of licensed agent's signature certifies the followin em Ip an g: "I certify that in the performance of the work for which this permit is issued, I shall not ploy y 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 persona subject to workhm ;' pensa- tion laws of Calico Is " The applicant 11 f 1 u' on Co pieta drawing on erse�i e. [/� y E Signed Title: /�/ Data: 17> FOR DEPARTMENT USE ONLY q � Application Accepted by Date # Area Pit or Grout Inspection by Date - _ Final Inspection by Date 3 Z Additional Comments. Applicant - Return all copies to: I - p AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 INFO AMOUNT DUE AMOUNT REmiTTEO CK L7 CASH RECEIVED BY DATE PERMIT'N0. r . EM 13.21(REV.Iiesi EH;1.26 2� V