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. :a APPLICATION FOR PERMIT N X � v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . 50 ENVIRONMENTAL HEALTH DIVISION 1601 E— RAZELTON AVE. , PHONE (209)468-3420 7 P O BOX 2009, STOCKTON, CA 95201 pZMIT EXPIRES 1 YEAR F&QM D SSUED (Complete in Triplicate) " Application is hereby made to Sa.n'Joaquin County for a permit to construct and/or install the work herein described. This application is made in complia.ncelwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 824 East Turner Ria CityLCdi Lot Size/Acreage aCx+< Cit Of Lodi Address 221 We t Pine Phone 333-6706 Owner's Name Y '11 Contractor Clark Well Inc Address 2024 E. Charter License No371 560 phone 462-7676 TYPE OF WELL/PUMP: NEW WELL}�kX WELL'REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 6" Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DomesticlPrivate i-1 Gravel Pack ❑ Tracy Type of Casing Steel Specifications Ik Public Cl Other n Delta Depth of Grout Seal 125 ' Type of Grout 9 sack I I Irrigation __ AppraxIDepth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR!ADDITION I I DESTRUCTION l I (No septic system permitted if ptiblic sewer is f 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 PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size II r FILTER BED ❑ Distance so nearest: Well Foundation Property Line SEF-PAGE PITS 11 Depth f Size Number SUMPS 0 Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ j k, 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 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 California." ` The applican t cal It ns cions. Complete drawing on reverse side. Signed Title: Date: 27 No3z 90k FO DEPARTMENT USE ONLY O Applica ' ccepted by Date •-' � � Area Pit �Grou6 coon C �^ Date�� Final Inspection by Date j S l Additional Comments: , Applicant – Return all copies to: San Joaquin County Public Health !/ „ [20-130clay pr-&v, c.4.cl�ef. Services, Environmental Health Permit/Services ^ zS g vets bt Fd�,f�c+o�r .s"'4 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 gIQO �(B tiz-��o•` �,rL� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. INFO CASH ' + EH 13.24[REV.I/H m97 d f EH?x•26