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APPLICATION <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 /> PERMIT F IRES 1—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 eampliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 125 S . Hutchins City Lodi Got Size/Acreage <br /> Mark Lindseth Engineer <br /> Owner's Name C i t y o f Lodi Addres2s 21 W Pine Phone 333-6706 <br /> Contractor Clark Well Address 2024 E , Charter Way 371560 462-7676 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 CTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Test <br /> & ­_THERM 3E Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES PROP, LINE +75 ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack F1Tracy Type of Casing_ Specifications <br /> X li,i%iblic CI Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Staling Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/AODITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial — Other �_ Q <br /> Number of living units: Number of bedrooms _ } <br /> Character of soil to a depth of 3 feet: a Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: WellFoundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size ti <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS p <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 signature certifies the following; "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 /> n laws of Cali rn s the following; "l certify th pe <br /> tion <br /> ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la .' <br /> The applican f r I g r ds m late drawing on reverse side, <br /> Signed Title: VP Clark Well , Inc Date; 2 5 Feb 92 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Oats Areas. <br /> Pit or Grout Inspection by Date Final Inspection by DateLEZ1 "a2 <br /> t <br /> Additions! Comments: <br /> Applicant - Return all copies t : San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San JquiIN O Bo 009, Stkn, CA 95201 <br /> FEE CK <br /> �INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> . EH 121(REV.I/w 51 jSL4 iy� t Q <br /> EH t4.b2e �-1, <br /> s —© <br />