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z APPLICATION + I 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 M1IRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) 1 i 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. 950 industrial; Way Stockton City_____C ^. .Lot Size/Acreage Job Address Mohr-Fry Ranches c/0 J e ry l Fry) 11-` 12b09 North West Lane/Lodi, C 209-3 4-3808 ' Owner's Name Marian A Mohr F ry Address none -- �-_ - - 1 1900 Powell Street Phone__51 0-652-450I Conttactor LeVlne-Fricke Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Li DESTRUCTION Cl Out of Service 'dell ❑ �] [� J . OTHER ❑ Monitoring Well Ll J011 BOrT1�g5 PUMP INSTALLATION ❑ SYSTEM REPAIR CJ E DISPOSAL FLD. PROP. LINE DISTANC TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications. C:1 Domestic/Private ❑ Gravel Pack L) Tracy Type of Casing._ Type of Grout Cl Public is Other n Delta Depth of Grow Seal I I lrfigation —Approx. Depth l I Eastern Surface Seal Installed by of Pump H.P. State Work Done Repair Work Done U , Type Sealing Material & Depth Well Destruction ❑ Well Diameter': �-- Filler Material 5 Depth Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1-1 DESTRUCTION I 1 alvo septic SY I m permitted en ted if public sewer is lable Installation will serve: Residence _ Commercial____ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: F. SEPTIC TANK ❑ Type/M19! Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. &,Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line r � SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance io nearest: Well Foundation Property Line DISPOSAL PONDS ❑ application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this y 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 of 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 recvers-e,side. Signed X Title: Date: • "I� FOR DEPARTMENT USE ONLY r t ��r Application Accepted by Date Area Pit or Grout inspection by Date Final inspection by Date ✓�-13 Additions! Comments: ilaw RA UIP Ay., � Applicant - Return all copies to: San Joaquin County Public Health Services ✓�Y] i Environmental Permit/Services � 445 N San Joaquinuin,, P P 0 Box 2009, Stkn, GA 95201 FEE I AMOUNT DUE B AMOUNT REMITTED ASH ECEIVED BY DATE f ERMIT NO. i INFO . EK 13-24 IREV.I/x sl �- 8Q N 323 EH 14.26 ' �