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'-� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRDS 1 YEAR FROM DATEED (Complete in Triplicate) P0044- (q1_-6Z-D 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 204 East Lodi AvejauQ City Ln 1 Lot Size/Acreage - 1 R ac _ Owner's Name Mary Lehr __ Address Phone 209-369-3215 4tV" 0T F.0'�'�`3 36, 0V LSk—i CA 554 Contractor - Address A License No. Phone 209-956-0 , 64 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well CX DISTANCE TO NEAREST: SEPTIC TANK n/a SEWER LINES 50 ft_ DISPOSAL FLD. PROP. LINE --45 FOUNDATION AGRICULTURE WELL _Il,C OTHER WELL 350 PITS/SUMPS _UJ_a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ $'' Dia. of Well Casing ' C1 Domestic/Private Qq Gravel Pack ❑ Tracy Type of Casing pVC Specifications -- I'I Public Cl Other n Delta Depth of Grout Seal 55 r Type of Grout Pnrt 1 and I I Irrigation �..Approx. Depth IXEastern Surface Seal Installed by� - _F_1 g5.t grey we l 1 rf}VPT'--- Repair Work Done U Type of Pump H.P. State Work Done _ 1 Well Destruction ❑ Well Diameter 8 " Sealing Material & Depth i Monitoring Depth 70 t Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feat.I 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 ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fbundation Property Line i • SEEPAGE PITS 11 Depth Sire Number SUMPS Ui Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 empioy persons subject to workman's compensa- tion laws of California." f The applicant st tl for all fired inspections. Complete drawing on reverse side. Signed X____ - __-- Title Date: FOR DEPARTIVI NT USE ONLY �] Application Accepted by Dare � � L Area Pit or Grout Inspection by EE Date L�✓' 2 Final Inspection r O y Jam. Date CO Additional Comments: !N I"1 QAW iv '1• C fOli iQ t!( � ZAPlicant - Return all copies to: San Joaquin Count Public Health Services, Environmental Health Permit/Services -Z.- 1601 Z 1b01 / E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 y�r FEE INFO AMOUNT DUE AMOUNT RREMITTEO SASH RECEIVED BY DATE PERMIT'NO. ` + EH EHi4.26IttEV.iin5l V4! �Y LL G2 cl--?, b -