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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION !; 445 N .SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 h ,, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application 18 made in' coaapliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Hubs and Regulations of San Joaquin County Public Health Services. 1 7Kettleman CityLodi - Lot Size/Acreage ob Ad rasa;F i�tvt Pa BQx 836 WnndJ1X-ir�ar' - Phone' 669- Owner's Name"a�00 Rittman Proper)=�4��ess _ -a� Contractor C l ark W e Y 1 Address 2-Q2- E License 1`03 7 1 5 6, Phone -� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ - PUMP INSTALLATIONS SYSTEM HE ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k } INTENDED iiTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial , 0 Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private 0-Gravel Pace L1Tracy Type of Casing– Specifications E" n Delta Depth of Grout Seal Type of Grout # l'1 Public 7 6 3 2 E . C1I:Qthec 3 �"m n .. 11 Irrigation s Appfox. epth�I I-_Eastern Surface Seal Installed by Repair Work Donne S�r, Yp4 of:Pu ► H.P. 1 n StatB�Work Done. _;o- -- t-- --- C`(1 1� O[�i�a[.66 s,�'��C . 3F_ti �f i �� rWt�V(31}1 �.CI�I 3V�M1J1 Jll Well'Deatruction ❑ Well Diameter Sealing Material & Filler Material & Depthr 1f I Depth !,, r i. TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is V available within 200 feet.) I Installation will serye: Residence Commei Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - :I Method of Disposal Distancetonearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED t n. Distance to ne�res�, Well ^I Foundation, Property Line �„. arae yy, will 1 JII AL x t /_III,,;]i L t Y 'C t L l t- u x Ci -;U Iti r i1 !S 11��t' t'1 i J I SEEPAGE PITS I I Depth ' Size Number"jA Ll r is Itis- i ; , , 4 i, « h. r,i 'i Distance to nearest: Well Foundation PropertyLing' SUMPS Ll D I DISPOSAL PONDS ❑ t 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 rules and regulations of the San Joaquin County 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, 1 shallnot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 compenda= tion laws of Calif nii The applican If for r re c ' Cc I drawing on reverse side. Signed X Title: —VP Clark Wp.11 Date: FOR DEPARTMENT USE ONLY _ Application Accepted b Date Area_.... – - Pit or Grout'Inspection T, Data r Final Inspection by T"f —r' � �� Data t tNc�l� Additional Comrs►ants Applicant Return all copies to: San Joaquin County Public Health Services f Environmental Health Permit/Services I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEN INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'N1-3 0. E13 M 13-'L4IAEV.1/x ,1 f k �sr t/CJ � Vii 1M tam + Y t_a.a I k W c1 I un 93