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APPLICATION FOR PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f/ ENVIRONMENTAL HEALTH DIVISION rd' 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE 19SUM (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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4897 E. BEAR CREEK ROAD City LODI Lot Size/Acreage Owner's Name CLARENCE CHILDERS Address 4897 E. BEAR CREEK ROAD, LODImone 369-5984 Contractor NOACK PUMP-CO. Address 4500 E. FREMONT, STOCKTQ(�ense No. 504513 Phone 948-8817 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 Industrial ❑ Open Bottom ❑ Manteca is, of Well Excavation Dia. of Well Casing Domestic/Private ❑-Gravel-Pack- r:--IL-7-Tracy- -Type-of Casing---• .-- : I Specifications �} I'I Public 1-7 Other n Delta Depth of Grout Seal Type of Grout I I Irrioation ...._..Approx, Depth I I Eastern Sufface Seal Installed by. Repair Work Done P Type of Pump SURMUSIBLL•P• State Work Done_ ADDED 21 r OF PIPE Well Destruction ❑ Well Diameter Sealing Material & Depth ETTINC Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION-[ i INo septic system permitted if public sewer is available within 200 feet.) 4 installation will serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms r r t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size o FILTER BED n Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth Size — Number SUMPS LI Distance to nearest: Well Foundation . _ Property Line DISPOSAL PONDS ❑ 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 cenifies the following: "l certify that in the performance of the work for which this permit is issued, I 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 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 Californi I The applicant must cat for I r ' di ti mplete drawing on reverse side. ' Signed YLO. r� L Title: RETAIL SALES Date: SEPTEMBER 26, 1990 E I FP&DEPARTMENT USE ONLY { Application Accepted by __ C." 4& Date -DI �.._ Area ` Pit or Grout Inspection by Date Final Inspection by Additional Comments: 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 OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO, INFO CASH . EH 13-24 IPEY.IY45S S 1iH i42E �.!