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r: APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> / ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> J PERMIT E%PIRES 1 -YEAR FROM DATE I ED <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 cmWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �g� <br /> Job Address 8400—W. Handel Road_ ,,,,_._..._.. �'"'t ity . Lodi Lot Size/Acreage <br /> 71ai�i:'. _ b <br /> owner's Name Harvey- Properties L;MiAress 8400_ E`.`-_4andel Rd. Phone 209-4768530 <br /> 'r <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ \v- WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t- _ "FOUNDATION —"" —""'—AGRICULTUAE-WE-CLo""*-- OTHER'WELL�= PITS/SUMPS-"---,--- �-- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ® Gravel Pack 0 Tracy Type of Casing Specifications <br /> f'1 Public rl Other '""' Cl Delta Depth of Grout Seal" Type of Grout <br /> I I Irrigation _Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> t Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ' Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms =a <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lineaTotal length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I YDepth Size Number <br /> SUMPS Ll Distanceto 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 /> Home owner or licensed agent's certifies the following:gs 's sig nature g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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 laws of California." <br /> The applicant must c I all required i spevions. Complete drawing on reverse side. <br /> Signed - Tine:Partner <br /> Date: <br /> ° <br /> FOR PARTMENT USE ONLY <br /> r ,l G- <br /> Application Accepted by Date _2 2 Area <br /> Pit or Grout IneWtion by Date Final Inspection by• �� Date <br /> t' <br /> Additional Comments: ~ <br /> Z::y— <br /> i <br /> Applicant - Return all copies tr San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009,(Stkn, CA 95201 <br /> CK <br /> FEE <br /> 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> liN; INtttfv.,,hs, Il � 7-� �J�-'�� <br /> F <br />