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APPLICATION `` — SAN adAQU1N COUNTY PUBLIC HE TS6A r ENVIRONMENTAL HEALTH DI IIS 445 N SAN JOAQUIN, PHONE (2 {� P 0 BOX 2009, STOCKTON, C A5dW PERMIT EXPIRES 1 YEAR FROM D TE {{ff UID O l (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. 549nd 1862 and the Rules and Regulations of San Joaquin County Public Health Services. CCi.ELL4a 2_ Job Address DeBROGGI RD. 6ax41-&%'z_5 c„y LODI Lot Size/Acreage Owner's Name FLAG CITY L. P . Address 1820 W. KETTLEMAN I I.ODIPhone 334-661 .1 Contractor HENNINGS RROS_ f1RT1 I Pddress 33,25 PFI AN[IA1 F Mf1f1FSTl1 License No. 2_CI0813—Phone TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER LINES 50 ' DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S rr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it.7V ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation 2 Dia. of Well Casing tr Cl Domestic/Private AGravel Peck ❑ Tracy Type of Casing_ S T E E L Specifications t�"9R X) Public ❑ Other n Delta Depth of Grout Seal Type of Grout 30 u C I I Initiation _Approx. Depth 1 I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction O Well Diameter Seals� Material i Depth r V Depth Filler Material L Depth \ _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Ileo septic system permitted it public rower is available within 210 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 O Type/Mfg Capacity No.pAclompartments PKG. TREATMENT PLT. L1McMi >QyI Distance to nearest: Well Foundation Property Y Ca he LEACHING LINE Ll No. 6 Length of lines Total Ion zq m FILTER BED ❑ Distance to nearest: Well Foundation JJ (LLp -,-T _— IflA I "-.47-M-v"fy rY fr SEEPAGE PITS 11 Depth Size Number k NAo.,s A] SUMPS LI Distance to nearest: Well Foundation Property Lina N 1- DISPOSAL PONDS ❑ \� I hereby cemfy that 1 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 canities the following: "I certify that in the performance of the work for which this permit is issued, 1 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 applicant,must cag for all required inspections. Complete drawing on rjaver side. Signed X 4. Ff1. �U /T;tla�10 �- Date: MAY 23. 1994 �,ry FOR DEPARTMENT USE ONLY Application Accepted by Data Area Z Pit or Grout Inspection by Final Inspection by Date r i v Additional Comments: _9L' 9 — Applicant - Return all copies to. Sa 0 County Public Health Services \ � O A, mud/ „ 1 tal Health Permit/Services S Joaquin, P O Box 2009, Stkn, CA 95201 / W f 7 •`e � • INFO MOUNT DUE T EMITTED CKSH AALI \ RECEIVED BY DATE MIT NO • EN I]]I IaEV.rrn51