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APPLICATION FOR PERMIT � 1 r t�C SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PA ENVIRONMENTAL HEALTH DIVISION 01 P 0 BUS 2009, STOCKTON, CA (209) 468-3447 FES �9 9 AN.10A N0 9I PERMIT (Complete in Triplicate) '�'v1,gE NMEN AL T;gSERNcY Application Is hereby imile,to San Joaquin County for a permit to construct and/or install the work herein 1. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations Joaquin County Public Health Services. 3 di CA 9524(lot size/AcreagrlPN 025-02-05 Job Address 16001 North Glasscock Rd. cit Owner's Name Marian Mohr Address 12605 No: West Lane Lodi Phone(209) 368-7769 240 c/o Jeryl R. Fry, Jr. 1830 Vernon St'., Ste. 7 X916) 969-52 2 Contractor UTEC LTD. Address Ros F eville CA 95678 License NP-57408595 Phon TYPE OF_WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Nell ❑ OTHER �.'seO.Mpi��r ] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑DISTANCE TO NEAREST; SEPTIC TANKNOS SEWER LINES DISPOSAL FLD.�nP PROP• L FOUNDATION _n AGiiICULTURE WELLI�— OTHER WELL 1�Me PITSI�UMPS DTa1.1e f� INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. We..,-Casing C� Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation .--- , Type of Casing Specifications U Domesticl Private Cl Gravel Pack. L7 Tracy yp Type of Grout ❑ Public 1-1 Other s ❑ Delta Depth of Grout Seal GI Irrigation —Approx. Depth ❑ Eastern Surface Saul Installed by Repair Work Done U 'type of Pump H.P. State Work Dane ; P Sealing Material i Depth eth Well Destruction © Well Diameter ` 1 n Depth a Filler Material Depth ^fie TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public sews is < ` available within 200 feet.) Installation will serve: Residence Commercial — Other ; Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED M Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Lina ` DISPOSAL PONDS ❑ 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 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_oat�r' employ any person in such manner as to become subject to wormman's compensation laws of California." Contractor's hiring of 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 laws of California." The applicant must call fo all required inspections. Complete drawing on reverse side. Signed Title: Princi Consultant Date: a FOR WPARTMENT USE ONLY Application Accepted by Date . Area i pit or Grout Inspection by Date Final Inspection by date r Additional Comments; Applicant - Return all copies to: SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES i I ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES # 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 06201 d iFEE AMOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMr7'NO. . EH U•Y�(REV-11A5WIT 7 EH A-42'6