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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A ENVIRONMENTAL HEALTH DIVISION q 1601 E. HAZELTON AVE. , PHONE (209)[468-3420° P O BOX 2009, STOCKTON, CA 95201 5AN M,qy 02e� � PERMIT EXPIRES 1 YEAR FROM DATE ISSH)4E�BC/r^°goUrN fog � (Complete in Triplicate) QNyj�T�9�TMCJ(/Nry Application is hereby made:to San Joaquin County for a permit to construct and/or install the vbrk here �df �F�i`1 This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Reguls f 0of San Joaquin County Public Health Services. Job Address _ ih--Cherokee_Lane___-______ _ City Lodi-_____ Lot Size/Acreage Owner's Name Ge41P_ke T.an T)Pyt-J pMP_n't Address I S_ Cberakee Lane Phone Contractor Wayne Drilling -Address.l!() BOX 726, Lincoln CA License No376-345 Phone 9.16- -93 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r1 t=1 Industrial ❑ Open Bottom CJ Manteca Dia- of Well Excavation )At" Dia. of Well Casing C] Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing___ eVo l Specifications Se- I.I Public Other CERTeA_")n Delta Depth of Grout Seal "OPAL tfa^ Type of Grout JOLT I I Irrigation 25YApprox. Depth I I Eastern Surface Seal Installed by WAY fJ 6_ D 21 t-;- Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter It !r Sealing Material & Depth 64IUT �-� GAG. goL W Depth SS r Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if p(rblip sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other x 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. C) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size 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 1 C,j DISPOSAL PONDS ❑ M 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 CL 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 applicant must call for all required inspections. Complete drawing on reverse side. L) Signed X Title: S6 E77 L-D A ST` Date: __ `� I 2-,e `>J WKENT USE ONLY / Application Accepted by Date - Aov A a y J Pit or Grout Inspection b Date -` S Final Inspection b Date f Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. u, /rte EH r3-241REV.I/p51 {V� �I snpo EH t4.2e LL I