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APPLICATION FOR PERMIT J ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 " (209) 468-3447 ! PERMIT F' IRES 1 YEAR��M DATE I;�SUED (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. Job Address 11013 N. Davis .Road City Lodi. Lot Size/Acreages acres Lewis F. and Barbara J. Owner's Name Van Buskirk Address 5173 N. Solari Ranch Rd. Phone — Stockton, CA 95207 Contractor J- B. McConnell Address P.O. Box 71 Oakdale cense No.Bl-252922 Phone - 7585 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEME T .. DESTRUCTION ❑ out of Service Well Cl dd PUMP INSTALLATION 0 SYSTEM REP IR Cl OTHER ❑ Monitoring Well G7 ,F 1 DISTANCE TO NEAREST: SEPTIC TANK II SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION Zo ELL OTHER WELL PITSlSUMPS _ INTENDED USE TYPE OF WELL PROBLEST UCTION SPECIFICATIONS Y n Industrial ❑ Open Bottom 0 MantWell Excavation Dia. of Well Casing ; U Domestic/Private 0 Gravel Pack 0 Tracy of Casing Specifications M Public 11 Other O Deltat of Grout Seal Type of Grout 0 Irrigation ^Approx. Depth —0 Easteace eul Installed by Repair Work Done L] Type of Pump State Work Done , \ Well Destruction ❑ Well Diameter erial DepthDepthrial . Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IR REPAIRIAODITION 0 DESTRUCTION 0 INo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve, Resid nCq Commercial X Other : \ Number of living units: 20W Number of bedrooms Character of soil to a depth of 3 feet:1 Clay _ Water table depth 45 feet SEPTIC TANK CK Type/Mfg - ecase collcrete . -_ Capacity 1500 gal• No. Compartments 2 , PKG. TREATMENT PLT. Cl I e s L_ i Method of Disposal Distance to nearest: Well undation _ 25 ft Property Line 120 ft. LEACHING LINE $I No. & Length of lines Total length/size 180 ft• F. FILTER BED 173 Distance to nearest: Well Foundation Property Line SEEPAGE PITS JJ Depth Sire Number SUMPS Cl Distance to nearest; Well 21710 ft-.Foundation_110 ft Property Line 5()t, ! DISPOSAL PONDS 0 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 rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not 'i employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature i 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 C 'forms." The applicant st I for II rewired inspaction� omplete drawing on reverse side. fSigned Title: � c i� _ Date, -� ' DEPARTMENT USE ONLY q Application Accepted by Date!v Area Plt Grout Inspection b t7ate�� 5 ��' Final Inspection by -� � ^ - Date I Additional Comments: Applicant - Return all copies t SAI ROAJIN COUNTY PUBLIC HEALTH SERVICES ENVIRONTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 r-ESE INFO AMOUNT DUE AMOUNT REMITTED CASFI RECEIVED BY DAATT]E �}� PERMIT'NO. 7y + EN 13-NIREv.i/M61 61 q ■O� [ �� ,firofl / `+ 70- - V EN �•?a