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APPLICATION _ 'r 52 4- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r :' 445 N SAN JOAQUIN, PHONE(209)469-3420 P 0 BOX 388,STOCKTON, CA 95201-0388 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address 13139 N: fP_i.�E LO D!_ t v LODi Lot Size/Acreage 1 Owner's Name = � , _ Address L400 N.ALPIME RD LQ �� 334 2 151 `, Phon Contractor .BAUwI Address 323 q, LODE I CA rJ c License No.tC l ! Phone 2 p( 6iic, TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G 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 `1 ❑ Industrial ❑ Open Bottom ❑ Mantecs Dia. of Well Excavation C.I Domestic/Private 0 Gravel PackDia. of Well Casing Q Tracy Type of Casing- � I'I Public is OtherSpecifications �l Delta depth of Grout Seal I lrrigauon A Type of Grout pprox, Depth I ! Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material ii Depth h TYPE [ tp�OF(}SEPTIC WORK- NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTI nsnOON I I fNo septic system permitted if public Bawer is Installation will Z la I� J � 3 ��-ll serve: Residence� Commercia rj--115 j] I available within 200 feet.) .,.` OtherNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity' No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line _ LEACHING LINE ❑ No. b Length of lines FILTER BED Total length/site Cl Distance to nearest. Well Foundation —_ Property Line �,. SEEPAGE PITS II Depth Si " =" Size Number SUMPS I_I Distance to nearest: Well DISPOSAL PONDS p Foundation�� Property Line I n tI t- ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county: rules and regulations of the San Joaquin County ordinances, slate.laws, and Home owner or licensed agent's signature certifies the following: "I certity that in the performance of the work f6r vftch thrs pdmlit rs iss'l ed, f sfrrrll not employ any person in such manner as to become subject to workmen'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 com tion laws of California." pensa- The applicant st calf for all required inspections. Complete drawing on reverse side. Signed r Title: � , Data: R DEPARTMENT USE ONLY Application Accepted by _ Date Area 1 J Pit or Grout Inspection by ! Date- � Final Inspection by Additional Comments: n /.4 _ Date f ' J Applicant - Return all copies tc: San Joaquin County Public Health Services 5 Environmental Health Permit/Services W�{,tJ L]r, 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201.0388 Co04t/ FEE �� e r } AMOU T DUE K �J I INFO AMOUNT REMITTED RECEIVED 8Y H DATE PERMIT'NO. EK 13,24 144EV. S d