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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1-YEAR FROM DA JM <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the vont herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 1 230 East Lodi Ave City Lot Size/Acreage <br /> Owner's Name City of Lodi Address 221 West Pirie Phone 333-6706 <br /> Contractor Clark Well, Inc Address 2024 E. Charter License No.—17156 0 Phone-462-2676 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 <br /> Test Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER C3 Monitoring Well. ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 500 ft Deep <br /> F7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation r�1 Dia. of Well Casing <br /> f} Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public Oiher n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth + o be drills �Q <br /> Depth Filler Material & Depth aft(-r aGf on _anzLt-her permit Q j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No 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 <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity--- No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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 /> certifies the followin "I 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 <br /> The app70t � <br /> r d inspections. Complete drawing on reverse side. <br /> Signed TitleUP _Clark_ Well.- IncDate9 Qct- 90 <br /> � ARTMENT USE ONLY <br /> Application Accepted by c ti L olu..r. Date - Area 1 <br /> 7 9�-&rell 't-,r dy <br /> Pit or Grout Inspection by Date� Final Inspect'o by �c-fin Date �� + <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Hea 1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 2 1 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. <br /> + EFI1321fREv.tin91 `47 1 J <br /> 1 �-5 -10 <br /> IEH a/-2a t L <br />