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aAPPLICATION 0 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 with San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of Sen Joaquin County Public Health Services, Job Address 804 AND 810 EAST BLACK DIAMOND WAY City LODI Lot Size/Acreage 33,500 SQUARE FEET Owner's Name MR. JOHN E. DONOVAN Address 225 WEST ELM STREET, SUITE C, Phone g1s�i LOD1, CA 5240 Contractor V & W DRILLING Address P.O. BOX 51 , RIO VISTA, cense NoC57-710678 phone 707 374-281 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XX �ffftorgft * ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 T SEWER LINES 50rr DISPOSAL FLD. PROP, LINE FOUNDATION _—IL— AGRICULTURE WELL 50' OTHER WELL UNKNOWN PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS BACKFILL 177 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing BORING C] Domestic/Private ❑ Gravel Pack+ ❑ Tracy Type of Casing_ NA Specifications CEMENT/ LES I'1 Public Cl Other Cl Delta Depth of Grout Seal 65 TO S$&� Type of GroutTEAN 57 BENT NIT I I Ifrivation ^Approx. Depth t I Eastern Surface Seul installed by Repair Work Done L3 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Hatertal i Depth TYPE OF S TIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION i I INo septic systam permitted if public sewer is available within 200 loot.) Installation will se 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 PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well dation Property Line LEACHING LINE �cl�Nngth of lines tai length/size FILTER BED 10 nearest: Well Foundation arty Line SEEPAGE P;0NDS S 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL Cl 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 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 manner as to become tublect to workman's compensation taws 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 California." The appiicantpwAat call for all4equirad inspections. Complete drawing on reverse side. Signed xr WC Title: �%� �� L7r {G`5+ r Date: VA0U �'� 7 F DEPARTMENT USE ONLY 1+ L -7 Application Accepted by Ly -61 Data f Area Pit or Grout Inspection by Data Final Inspec[i in by Da e Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services � Environmental Health Permit/Services 0 415 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13.74 HEV. i e al15�*11 --' Page 13,,; EH 1 .76