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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 /> pERM T E%PIRES YE FR Y D TE 1S§UED <br /> (Complete in Triplicate) <br /> vorkin <br /> Application is hereby made t, San Joaquin co my fora permit t) ditnancenstruct No. 549aando18628tall and theeRules andeRegulations Of Sans <br /> application is made in cceiliance with San <br /> Joaquin County Public Health services. Lodi 10 acres <br /> 815 L o c k e f o r d St City Lot Size/Acreage <br /> Job Address <br /> Address <br /> P • Phone - <br /> Owner's Name C <br /> r Cortitractor C l a r <br /> Well.. I Address <br /> � . Charter Way,. License No-371� 5_ 60 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW eil 0 <br /> WELL 11 WELL REPLACEMENT [l DESTRUCTION ❑ put Monitoring well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ Te s t Wel PTHERXOX <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK —�- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of We 11 Casing (ti, <br /> L, Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation <br /> Casing- Specifications \ <br /> [I Domestic/Private . ❑ Gravel Pack Type of C <br /> 0 Tracy Depth of asingGrout Seal Type of Grout <br /> — <br /> I'] Public 1-10ther n Delta <br /> I I Irrigation Approx. Depth I I Eastern Surface Seat Installed by f\ <br /> 01 Pump - H.P. ' State Work Done_ fl <br /> Repair Work Done L7 Type Sealing Material i Depth <br /> Well Destruction ❑ Well.Diameter Filler Material i Depth <br /> Depth gi, s ilted if public sews► is <br /> PS 0mil <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAlR1AD I r i f 1.1 <br /> lristalMtion will.serve: Residence— C <br /> ommercial— Other <br /> Number of living units: Number of bedrooms permit may have expired withOOUtt h <br /> Character of sail to a depth of 3 feet: rtmente <br /> SEPTIC TANK ❑ Type/Mfg WI,O� j It <br /> PKG. TREATMENT PLT.Q by EI ivirOnmei s1ai Heait�,j tpaaal <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. 3 Length of lines Property Lino <br /> FILTER"BED ❑ Distance to nearest: Well Foundation <br /> I I Depth Size Number <br /> SEEPAGE PITS Property Lino <br /> SUMPS Ul Distance to nearest: Well Foundation <br /> i DISPOSAL PONDS ❑ I' <br /> � certify that in the performance o1 the work for which this per <br /> I haroby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rulesHome owner or licensed agent's signature certifies the fa "I mit is issued, I ahaN not <br /> les and regulations of the San Joaquin County flowing: <br /> s to become subject to workman <br /> employ any Person in such manner a 's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: " c hat in performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa <br /> tion Is"of Calif in ' <br /> The applicant for red pectic . Complete drawing on reverse side. 11 M a r C�1 93 <br /> Title _Clark Clark We11 Date: <br /> Signed _ <br /> FOft DEPARTMENT USE ONLY- o � � <br /> Area <br /> Application Accepted by <br /> s Deta <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return,-all copies to: San Joaquin County Public Health Services y <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> 91 <br /> FEE CK RECEIVED SY 0 TE PERMIT-NO <br /> INfO AMOUNT DUE AMOU T REMITTED H <br /> ♦ EN 13•24 IItEV.i/w 51 W <br /> EM 14.76 <br /> / <br />