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APPLICATION 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 EXPIRES 1 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 compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic_eg. Job Address 1100 lJe,6y. P_a_L ..a2 Rd City .Lodi Lot Size/Acreage 20ac ze,6 Owner's Name 17.ike Kennedy Address'1ame Phone 368-7565 Contiactor UcLl k 1•1e.0-i, Inc Address 2024 C. Chair,.te2 License No.371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL-Oc WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service We11 ❑ PUMP INSTALLATION-05 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK t I Q 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Indu I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (1 � Dia. of Well Casing n El omestic Private MAGravel Pack ❑ Tracy Type of Casin Specifications-,,.Z$& '1 Pu 1-1 Other ❑ Delta Depth of Grout Seal 5 Q! Type of Grout 9 6 rj 4xffiigation —.Approx. Depth t I Eastern Surface Seal Installed by C QCi/Lk Repair W k Done 0 Type of Pump •Sale H.P. 15 State Work Done ^ c f c 0 0 d W eatruclion ❑ Well Diameter Sealing Material & Depth Depth _ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I i DESTRUCTION I I (No 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 ❑ Type/Mfg Capacity--- No. Compartments ! �f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHIIQG LINE Cl No. & Length of lines Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ^T SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 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 man s t become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I ify that i th rformance of the work for which this permit is issued, I shall emptoy persons subject to workman's compensa- tion laws of Ca' mi .' The applic in t Ifo all eq red i on Complete drawing on reverse side. Signed Title:VP Cialc k Vp_ei, Inc Date: 10/26/92 FO D T USE ONLY Application Accepted by Data . -1 011�-_'014--^ Area © 1�- 1� Pit;or Grout Inspection by +ata LL--t ctL-Final Inspection by 1-111 Date 3 Additional Comments: C Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1F 0 EE AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATEq PERMIT'NO. . EN 5i�•2a 93-11 i(REV.I/H 51 13 r O D 3 t 0 USCF ��-� !Z Z '7' EN _