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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> . 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San � <br /> Joaquin County Public Health services. i <br /> k <br /> Job Address <br /> 6690 Hai ht Rd.1 City Lodi Lot Size/Acreage <br /> Owner's Nart�teve Rodacker Address 6690 Haight R0Ad JLn 52 _0Phone — <br /> 2644 <br /> Conhactorp r'vi ancp <br /> "dress License No.�-Phone — <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT LI DESTRUCTION ❑'Out of Service well ❑ <br /> OTHER ❑ Monitoring Well Li <br /> . PUMP INSTALLATION 2 SYSTEM REPAIR L7 � ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> i=7 Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Specifications <br /> W Domestic/Private 0 Grave! Pack M Tracy Type of Casing_ <br /> I'! Public <br /> C) Other Cl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation — Approx. Depth I I Eastern Surface Sedl installed by <br /> H p 5 State Work Done <br /> Repair Work Done C7 Type of Pump �� sealing Material & Depth <br /> \(� <br /> Well Destruction ❑ Well Diameter Filler Material 8 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I afvailabetic shin system rented it public sewer is <br /> Installation will serve: Residence Commercial_ Other r <br /> Number of living u�iits: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE ❑ No. & Length-of lines Total length/size <br /> s <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth a Size Number ` <br /> SUMPS 0 Distance to nearest: well Foundation _. - Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> ing: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the follow <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> 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- <br /> tion la lifornla." <br /> Th applicant t call for al r vire nspeptions. Coehplete drawing on reverse side. <br /> Title: Corp. Secretary Date: 5/12/93 <br /> Sign _ r�-� <br /> PARTMENT USE ONLY {Z 1"' <br /> Application Accepted by i4i <br /> Date Z Area <br /> Pit or Grout Inspection by Date Final Inspection by ate�9? <br /> t <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> d <br /> ZEE AMOVNT DU12 AMOUNT REMITTED SH RECEIVED BY D TE PERMIT'NO, <br /> 56 <br /> EH 13.21(REV.i/ns) �'D �vDEH t1.Ia <br />