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a.., APPLICATION 3. S- JOAQUIN COUNTY PUBLIC HEALTHOSSERVICES C ENVIRONMENTAHEALTH DIVISION ' 445 N SAN JOAUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate): Applicationfie 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 Asdinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County'Public Health Services. J, r Job Address ° a LODI City LOD�_ Lot Size/Acreage Z (f �ok YL 61 �tlbt.] 2. U �1DaLE 7J�- Phone Owner's Name t Address Contractor �� S� i✓� _Address 4Lo � aJ License r�o. 71)i2 Phone 2Qg- 'a7 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION.❑:Out of Service Well 0 1 PUMP INSTALLATION .0. SYSTEM REPAIR ❑ 'OTHER ❑ Monitoring Well w( DISTANCE TO NEAREST: SEPTIC TANK -- SI=WER"LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL. yon PITS/SUMPS CONSTRUCTION SPECIFICATIONS - INTENDED USE TYPE OF WELL PROBLEM AREA r :;+ 2(. ii nindustrial j ; , ❑ Open Bottom " ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-7 Domestic/Private ❑ Gravel Pack ❑ Tracy" Type of Casing_ Pv�" Specifications I'1 Public G ., :`�1 Other Ckm& n Delta" � Depth of Grout Seal �8 __- _ Type of Grout 11 Irrigation ,Approx, Depth Eastern Surface Seat Installed by S Lam" w��[ r Repair Work Done 0 Type of Pump H.P. State Work.Done 4 Well Destruction " Well Diameter Sealing Material & Depth C1 (� l Depth 75 Filler Material & Depth aP Q TYPE OF SEPTIC WORK: NEW INSTALLATION I"1 REPAIR/ADDITION i I DESTRUCTION I 1 iNo septic system permitted if public sewer is i1available within 2170 feet.) l Installation will serve: 'Residence_ Commercial _:` Other I 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. Compartme is PKG. TREATMENT PLT. ❑ _ „ Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE I r0 No. & Length of lines Total length/size F i' FILTER BED "D Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS 11 Depth Sire - Number r SUMPS LI Distance to nearest: Well Foundation Property Line ` 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 l' rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such rttanner 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 Cali ornia." E The applicants usL II fora a uired inspections. Complete drawing'on reeVerse side. Signed X _____.. Title: f�n1 �ff Date: 113 FOR DEPARTMENT USE ONLY R Application Accepted by " _ _ � Date Area Pit or Grout lhspecuon by Date Final InnneCtion by date ll sl fi ao Additional Comments: a Applicant :- Return all copies to: San Joaquin County'Public Health Services Environmental Health'Permit/Services 445 N San.-Joaquin, P:O Box 2049, Stkn, CA 95201 1. - yFIO� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY - "DATE �� P�ERM///CCCIT"NO.nr . EM 13-24 IR lire!1� ��. OU U�•�v. -s - _�Vl m�'l�r 1 _ �' ✓+055a EH 14.21 L