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APPLICATION <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 Y SAN JOAQUIN, PHONE (209)468-3420 <br /> 0 BOX 2009, STOCXTON, CA 95201 <br /> PSIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San County for a pe:- t to construct and/or -Install the vorx herein cesc_ibed. This <br /> application is made in compliance v1-" Sam Joaquin County Ordinance No. 549 and 1862 and the aures and Regt:_ations of San <br /> Joaquin County Public health Services. <br /> Job Address <br /> 820 S . Cherokee C Lodi Lot Size/Acreage <br /> �tv <br /> 720 Nichols Blvd . <br /> Owner's Name Lance Ellis Address Sparks , NV 89434 Phone702-358-4134 <br /> Service P . O . Box 950 209- <br /> Contractor Oil Equipment/ zceressSan Andreas , CA95249 License No. 323417 Pnone794-1 8n8 <br /> TYPE OF WELL/PUMP: NEN 1.V=-;-L = WELL REPLACEMENT :_, DESTRUCTION _ Out of Service Wel_ G <br /> PUMP INSTALLA'CN = SYSTEM REPAIR OTHER = Monitoring We-- <br /> DISTANCE <br /> elDISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES close DISPOSAL FLO. PROP. LINESL— <br /> FOUNDATION <br /> tFOUNDATION 20 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom Z Manteca Oia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pacx ^ Tracy Type of Casing_ Specifications <br /> "I Public I"X Other : Delta Depth of Grout Seal Type of Grout <br /> I i Irritation _Approx. Depth Eastern Surfacs Seel Installed by f <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLA`CN I : REPAIR/AOOITION I i DESTRUCTION I (No septic system permitted it puolic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Cor-trnercmal _ Other <br /> Number of living units: Numoer of osdrooms <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK G TyperMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length c: ines Total length size <br /> FILTER BED G Distance :a nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Numoer 1 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> I <br /> DISPOSAL PONDS C <br /> I mill certify that I have prepared this appacation and :nat the work .vul JB done m dCLdrdanCe with jdn Joaquin county ordinances. state Taws, and <br /> rules and regulations of the San Joaquin City <br /> Home owner or!icensed agent's signature cef-fios:me following: "I certity that in tme performance of :ris work for whicn this permit s asued. I shall not <br /> emomov anv person in such manner as to clecome suoiec: !o workman s compensation laws of California. ' Contractor s miring or sub-•:ontrac:ing signature <br /> candies the certify that in the penzrrn ca of the work .or tivnicn this permit s issued, I snaii smoiov persons sup ect to wpr:man's cpm <br /> + p I <br /> ;ion la of Californi .' pensa- <br /> Th pplicant u call f r i Complete drawing on reverse side. <br /> Sig Title: President 11-5-92 <br /> eith A . al is Oats: <br /> FOR DEPARTMENT USE ONLY �i <br /> Aopfication Accepted by oats / (3 Area <br /> Pit or Grout Inspection by Oats Final Inspection y <br /> f� Dats <br /> Additional Comments: <br /> applicant - Return all cozies :__ San ,;oaquin County ?tib Health Services <br /> _aviroamental Health P t, Services ? /00 <br /> S� <br /> 445 N San Joaquin. ? 0 sox zoog, Stkn, '; ?5201 ) <br /> FEE AMOUNT CUE AMOUNT REMITTED I X s <br /> :NFO _RSH RECEIVED By GATE PERMIT .VO. <br /> I tYC Od <br /> Em <br /> 13-41IREV.i,wl1, [ IT6el7 l-J-4 //b'/93 3-OD31 <br />