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APPLICATION FOR PERMIT ,I SAN .TOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONHENTAL .HEALTH DIVISION iI =i 1601 E. HAZELTON AVE. , PHONE (209)488-3420 { P 0 BOX 2009, STOCKTON, CA 95201. Y 'i E EXPIRES YEAR FROM DAIE 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 :862 and the Rules and Regulations of San Joaquin County Public Health Services. , Job Address 2104 EaSt Lodi City T.r)d i '' Lot Size/Acreage �I Owner's Name 'Mary Lehr _ Address Phone „ Waadwe_- PD•$ZY-3 3tp %oVbi< CA I se,?l 637—Phone 2 Q 9- 6,:Contractor _ _Addressl A License Na. TYPE OF WELLIIPUMP: NEW WELL ❑ WELL REPLACEMENT Li DESTRUCTION Ei out of Service Ne,l ''G i PUMP INSTALLATION 13SYSTEM REPAIR 0OTHER C1 Monitoring Well li DISTANCE TO NEAREST: SEPTIC TANK n/a SEWER LINES 50 ft- - - DISPOSAL FLO, PROP. LINE _45 FOUNDATION 15 fiw AGRICULTURE WELL n/� OTHER WELL 350 PITS/SUMPS .D.Ld INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 0 Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation A " I — Dia. of Well Casing C) Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing Specifications 1: i'I Public fa Other f1 Delta Depth of Grout Seal 55 ' Type of Grout Pnrt1 and`: I I Irrigation ^Approx. Depth IX Eastern Surface Seal Installed by Ellishgray we}11 co-Nrer Repair Work Done U Type of Pump H.P. State Work Done, Well Destruction; ❑ Well Diameter _8"_ - Sealing Material & Depth Monitoring Depth 7 0 1 Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I Z (No septic system permitted it public sewer is available within 200 IeatJ Installation will serve: Residence Commercial_ Other r i Number of living units: Number of bedrooms �! Character of soil to a depth of 3 feet: Water table depth l i� SEPTIC TANK. ❑ Type/Mfg Capacity = No. Compartments PKG. TREATMENT PLT.0 Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/site FILTER BED © Distance to nearest: Well Foundation Property line it SEEPAGE PITS" 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature candies the following: 1 certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." II The applicant,196t9011 for all ired inspections. Complete drawing on reverse side. I Signed Title: Date: 3 FOR DEPARTM NT USE ONLY I!' t Application Accepted by 2� / LO?::� -- Date L Area t-/ !E Pit or Grout Inspection by Date FinaInspection y + " / -U Oate rb-Additional Comments: f [al fV� Applicant - Return all copies to: San Joaquin County Public Health ,I ; Services, Enyiroawntal Health Permit/Services f 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA, 95201 ,NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY GATE PERMIT'No. EH ty2�rRt.N.+rasa . Oa fCD 30 �- 3•tl•q2 q�• ° � EH i