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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 k <br /> YEAR E&QM <br /> (Complete in Triplicate) <br /> aPplication is hmadebin ccmwliance vithuin SanCounty Joaquinar a county Ordinancermit to No. <br /> 549$andp1862install <br /> and thethe <br /> Rules andherein <br /> Regulationsdescribed. <br /> of SenThis <br /> PP <br /> Joaquin County Public Health Services. <br /> Job Address <br /> 23160 N. Davis Rd. City Lodi Lot Size/Acreage 80 acres <br /> Owner's Name <br /> Panella Trucking--Robert Pan ess x5000 E. Fremont, Stockton Phone 943-5000 <br /> Contractor <br /> Hennings Bros. Address 3525 Pelandale, Mod. License No, 290813 Phone 545-1185 <br /> Out of Service Well <br /> TYPE OF WELL/PUMP: NEW WELL X}( WELL REPLACEMENT ❑ DESTRUCTION Ll ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER O Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 150++ SEWER LINES _ — DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 1 <br /> O t+ PITSISUMPS _ <br /> AGRICULTURE WELL OTHER WELL._....- � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 C tl <br /> F1 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing tJ <br /> Type of Casing steel Specifications 1l4Caa <br /> L) Domestic/Private (Gravel Pack 0 Tracy yP t Type of Grout30" Conducto <br /> M Public I-.1 Other ❑ Delta Depth of Grout Seal 50 <br /> driller Cemented in <br /> uIniUation �­Approx. Depth 0 Eastern Surface Seal Installed by i <br /> Repair Work Done U Type of Pump H.P. State Work Done_. <br /> Well Destruction O .-Well Diameter <br /> Sealing Material & Depth <br /> �3 c,r. Depth Filler Material & Depth ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRlAODITION 7 DESTRUCTION G INo septic system permitted if public sewer is <br /> avaiiable within 200 feet,) <br /> Installation wi)Irserve j Residence - `'Commr3rcial_ Other"I <br /> r <br /> r <br /> Number of living units: Number of bedrooms f �,�,� , C;f.� {clw li.r .Water table depth <br /> Character of Boil to a depth'of 3 feet- <br /> SEPTIC TANK ❑ Type/Mfg r v Capacity No. Compartments <br /> PKG, TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r, <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line 16" <br /> + <br /> F. <br /> SEEPAGE PITS I I~ Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property,Line I # 1 n <br />� DISPOSAL PONDS ❑ � •" _ <br /> I hereby certify that I hove prepared this aprdance w <br /> plication and that the work will be done in accoith San Joaquin county"ordinances;state laws grid <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the foilowing. "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifles 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• <br /> tion laws of California." <br /> The applicant must call for all required insPections. Complete drawin n verse a <br /> Signed Title: Date: - <br /> 6-91 <br /> FOR EPA ENT USE ONLY. <br /> Applieatio Accepted by Date ` Area — <br /> Pit Grout i ction Date i8-,9 Final Inspection by Date <br /> t � � <br /> y Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A�f-SS <br /> ENVIRONMENTAL HEALTH DIVISION PERM IT/SERVIC St - Q CPh}� � h Cf�gdd +� <br /> !c <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 G� �( <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. <br /> INFO (] (�way <br /> rR <br /> . EN 1S-2a EV,i i n a+ �`^'1 <br /> EH",,�•� C1 1 fkJ\ <br />