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APPLICATION FOR PERMIT 80-5235-93 SAN. JOAQU I N COUNTY PUBLIC HEALTH SERVICES Power Env Services ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (249) 468-3447 MAR 19 1993 PERMIT EXPIRES I YEAR PR011[ DATE IUM (Complete is Triplicate) ENVIRO�1/N�MEGNFTTALHHEekTH P � dVILY'1'DYd: %hia Application Is hereby atade,t0 San Joaquin County for a permit to construct and/or install the work herein e application is made in cotwliance with San Joaquin County Or"nanca No. 549 "t and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Parcel 05513015 Ci,. Lot Sime/Acreage 200 'x400 ' Owner'eName Cit of Lodi Address 12751 N. Thornton Rd Pho,,209 333-6749 Contractor Spectrum ExploraiAidpv, 2825 E. Myrtle_ License No. 51226$ Phone209 465-87 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service weelliW11 ❑ C7 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 7 ( gnieJO Geo g 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 n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public I:7 Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Dor)q,� Well Destruction © WO Diameter 6?1 Sealing Material a Depth Gement/ is-n onl e Depth _ 401 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION 0 DESTRUCTION CI (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 ■ depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ri PKG. TREATMENT PLT.Ct Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. $ Length of lines Total length/size FILTER BED 0 Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL, PONDS Cl I hereby comity 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 subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 appli est m st call for all required ins Cti s Complete drawing on reverse side. Signed Title: Manager _ ______ Date: 3-19-93 FO I,90ARTMIENT USE ONLY Application Accepted by Date -Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTEO RECEIVED BY DAT PERRMIT'NO. + EH 13-24 RIEV.+/ws) ✓S r EH14-2111 Com/ �