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APPLICATION FOR PERMIT 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 MIRES I. YEAR FROM DATE 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 ecarg1llance xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Fuhlic Health Services. Jab Address 13233 N D a v i lis Rd _ City Lodi Lot Si ze/Acreage5 2 A c res Owner's Name R 01 a nd N a k a t a Address 13935 , D a y_;P_§ Rd ._. _ ___. Phone 333-3804 Contractor C1ark-We11 -_Address 2-024 _E . ChartP-r-__ LicenseNo.3J1_._. Phone469-767 TYPE OF WELL/PUMP: NEW WELL ®x WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION px SYSTEM REPAIR C] OTHER C7 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK{-1 00 SEWER LINES DISPOSAL FLD. PROP. LINE +300 r i FOUNDATION AGRICULTURE WELL *1,5-W OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J-4 ti Dia. of Well Casing art X k.womestic/Private x XCJ Gravel Pack 0 Tracy Type of Casing_ Steel ___ -___ Specifications _ I'I Public 1-1 Other fl Delta Depth of Grout Seal t Type of Grout. I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by C l a r k Repair Work Dane 0 Type of Pump CC„b H,P. 5 State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth 1 .7 Depth biller Material i Depth V' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Q Type/Mfg Capacity No. Compartments G PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line I LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 San 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, I shall not employ any person in such manner as to become subject to workman'a compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol1owing: "I certify that in the performance of t work for which this permit is issued,1 shall employ persons subject to workman's compenss• tion laws of CalNornla." The applicant t It fo all at drawing on reverse side. Signed Clark Well , Inc .... Date: _ b M a i 93 F R DEPARTMENT USE ONLY Application Accepted by Z_ Date -SArea 02. �0 Pitr Grout tion by ct3ate �O Final Inspection by 6 Date 6 Additional Comments: Applicant - Re rn all,copir to: San Joaqu a County Public Health Services , CL4-� : 7?_1,,cC) Environmental Health Permit/Services f 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 rTi INFO AMOUNT DUE OUNT REMITTED I CK I CASH RECEIVED BY DATE PERMITal . EM 13.24 IREV.1/n 51 ` C.� ^�14•Z!