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�A� API ON FOR PERMIT 101, SAN ^ 1'�'�" S s � AUNTY PUBLIC HEALTH SIs'RVICES 79i TAL HEALTH DIVISION STOCKTON, CA 95201 (209) 46-8-� L/6 =3 y zv S jO G�,P+'P IT E%PIRES 7 YEAR I�ROi� DATE TSSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in caatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 13.cac�o• Ser.✓#,r<_ Si t_r,•u�. Job Address 100 Soar)% CA Cro Ktt Lti6 ys� City Lodi, C-i Lot Size/Acreage SSS 00o ErL Owner's Name U I rrq/m 4%r, Z^mac-• Add ass�,hc�SL�S Wis r ri^,'rd Si., I�a�. oma./ C�9 Phone �P©� z / , Co- Se - Contractor Wei- 'r}q�_�_Address �. t- c��Gf License No. Say C1 �� Phone"8.7..76 TYPE OF WELL/PUMP: NEW WELL Ge ( WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK ty SEWER LINES t yu�/}5" DISPOSAL FLO. NA PROP. LINEI_ ivu Aw-,2S/VW-L C FOUNDATION B��"" AGRICULTURE WELL 6 '9 OTHER WELL 0� fr � PITS/SUMPS N4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial O Open Bottom O Manteca Dia. of Well Excavation ", 2" Dia. of Well Casing Z U Domestic/Private Cl Gravel Pack O Tracy Type of Casing PVC- Specifications Q Public l;Other O Delta Depth of Grout Seal Irri T CJ anon �S�` Type of Grout Ns"f' Ct+..e•+�r U .�v1(pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter L 17 Sealing Material & Depth Ne.,,- cc,.,.e—Z;, v °ya Z56,,' J7r Depth 3'.fV 6 O Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION C1 DESTRUCTION CI (No septic system permitted it 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 Q SEPTIC TANK O Type/Mfg Capacity No. Compartments �" PKG. TREATMENT PLT. ❑ Method of Disposal _ (i Distance to nearest: Well Foundation Property Line ('11 LEACHING LINE O 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 subcontracting 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed JaJ A EV+)cT"c=ti I',�.Title: X(r y6 35' Date: 218 l 5l F DEPA USE ONLY �} Application Accepted by Date ! res Pit or Grout Inspection by Date Final Inspection Dets Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED Y INFO CASH DATE PERMIT NO. iv 1.I0