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• APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 2150 Ncdh Chex��ee- L Lodi 3 z Job Address `� City Lot Size/Acreage Owner's Nama v 1 1 UI l.x.E-1 1�-t N d� Address -+ I b 9s L -X519 O r a o�n QLD Ser•U f 4Ze5 iimfatu�'iiLe�lA�c.s Contractor Address LI ense No.t7y X6 Phone - 1 TYPE OF WELL/PUMP: NEW WELL O WTtL REPLACEMENT n t,�D�ESTRUCTION ❑ Out of Service Nell D La PUMP INSTALLATION ❑ SYSTEM REPAIR ❑soil tca UJ5```��`O��'TyyyH��ER� Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,� DISPOSAL FLA. NI_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t�� PITS/SUMPS ,,,, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6W 6-U Ch lJu.°r IE`K'.Li ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications��st Il Public j 1 Other n Delta Depth of Grout Seal Type of Grout f I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by ��'w�"� ./ Repair Work Done ❑ Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if 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 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 sub-contracting signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensa. tion laws of California." The applicant ust call for all r uir d in�sp�ec/t�ions. Complete drawing on reverse side. ,u. . Signed K �K [�(�-�� Title: 1 0 lffm ��g*VVlte: FOR DEPARTMENT USE ONLY Application Accepted by Date (� `' Area / �- Pit or Grout Inspection bycs2 ate `� Final Inspection by �,( • Date 5 S Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IN AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EHia-7.(REV.I/nal `�� ato$�3 2n 513 1"(S 0659 EH 14 Ie