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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIX EXPIRES 1 YEAR FROM DATE ISSUED 2:r• 1-Ml_.�4 �E,.J _ 4 I,/5 ,t-(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. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health services.,,-, IYO& 7d- Job Address NW Corner Lodi Grape Bowl City Lodi Lot Size/Acreage Owner's Name City Of Lodi Address 221 West Pine , Phone 333-6706 Contractor Clark Well, 1nC Address 2024 E. Charter License No. 371_�Q_ Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ Test Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F.] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation $" Dia: of Well Casing 4 El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications XXPublic Ia Other n Delta Depth of Grout Seal Type of Grout i 1 , I { irrigation 50 1111-Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material & DepthAfter Test inq douia w ell will Depth Filler Material & Depth either reeml- �an_d_an ' q eCl under r: TYPE OF SEPTIC,WORK: .NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sR"Wl available within 200 feet.l Installation will serve: Residence — Commercial— Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑' `TYpe/Mfg Capacity No. Compartments �_n PKG. TREATMENT PLT. ® Method of Disposal-. Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �y k a SEEPAGE PITS l I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 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`th'is permit is issued;I ghalI noii employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contraciing.signature: I 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," ; /�• awing on reverse side.The applicantust call r all rquir r Com to Signed xl Title: VP Clark Weli IncDate: 10 C)r-t 9 --- F DEPARTMENT USE ONLY t C D" Application Accepted by Date 1` l�- Area A la�� G. 4,-�q Pit or Grout Inspection by Date Final Inspection by -k Date _ G Additional Comments: n Ot �of`AS 2 5-1 0 of'�a"s Applicant - Return all copies to: San Joaquin County Public Health S 7f Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE ( rA/}MOUNT REMIT-TED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 q i•0D A EH :1-2B Y f r