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4 PPLIC'1T?nN SAN JOAt; IN COUNTY PUBLIC HEALTH SERKCES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. Job Address 950 industrial Way City Stockton_ Lot Size/Acreage Mohr-Fry Ranches C/o Jeryl Fry) Owner's Name Marian Mohr Fry Address 12609 North West Lane/Lodi, CPhone 209-334-3808 Levine-Fricke 1900 Powell Street Contractor Address License No. Phone 510-652-4500 TYPE OF WELL/PUMP: NEW WELL 1] WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ hagd augers PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C]of Bor qs DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public (.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION 1 I DESTRUCTION I I Mo septic system permitted if public sewer is Z 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 SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size C1't FILTER BED CI 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 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 applica/t must call for all squired inspections. Complete drawing on reeverse,side. / Signed X Com' Title: �-�'►`raY, 4y,4 -3N `y Date: • �-�`t/�-_-FOR DEPARTMENT USE ONLY T Application Accepted by Date —_� Area Pit or Grout Inspection by Date Final Inspection by Date-23-4--93- Additional ate .3- --93Additional Comments: vil IVL 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH ECEIVED BY DATE PERMIT'NO, EH13.24 IREV.r i n s1 �- Q.;/Q �. 3 g 3 -00 EH 1420