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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 • ,� P O BOX 2009, STOCKTON, CA 95201 _ w OPERMIT EXPIRES I YEAR FROM DATE ISSUED I+ (Complete in Triplicate) Application is hereby made to Sant Joaquin County for a permit to construct and/or install the work herein described. This l 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. �p J, Job Addressi eJ �; „• •,__„_-- ( Acreage r _ Owner's Name Address Phone Contractor t ?Srdress W rise Nott'/ s Phone �` f TYPE Of WELL/PU P: NEW I ELL L] WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ; t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ' [:l Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications 1'1 Public f El Other E Cl Delta Depth of Grout Seal of Grout �( I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by - 1 Repair Work Done L7 Type of Pump H,P. State Work Done_. O Well Destruction O Well Diameter sling Material & Depth Depth I Filler Material & Depth TYPE OF SEPTIC_WOR K. NEW INSTALLATION f REPAIR/ADDITION I 1 DESTRUCTION I t INo septic system permitted if'public sewer is { � available wiihin 200 feet.)' t installation will serve: Residence J�-- Commercial— Other-,— Number thersNumber of living units: Number of drooms r xr/ Character of soil to a depth of 3 feet: �r Water table depth SEPTIC TANK. ❑ Type/MfgCapacityNo. Compartments f PKG. TREATMENT PLT. 0 ”' If Method ot Disposal Distance to nearest Well/W4 Foundation! Property Line _ LEACHING LINE ❑ NoA Length of lines _R �'� Total length/size FILTER BED ❑ Distance to nearest: WelllBE74 Foundation - _ Property Line _gl� SEEPAGE PITS it Depth mic Size Number �UM Cl Distance to nearest: Well Foundation� Property Line DD ST POSAL PONDS ❑ I- I hereby certify that I have pripared this application and that the work wilt 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: '9 certify that in the performance of the worts for which this permit is issued, I shall not employ any person in such mann6r as to'becoms 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 taws of California." The applicant must call for all requir in{ coons. Complet drawing on r verse side. Signed Title: Date: a O DEPARTMENT USE ONLY f � q Application Accepted by Date rZ" Area �2 Pit or Grout Inspection by i Date Final Inspection by Dat'ILL— Additional Comments: ° r t Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services -i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 _N FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE tP?ERMIT'NO. y`i4241REV.r/A5) SN