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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 j <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance 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 4754 E. Woodbridge Rd City Lodi Lot Size/Acreage <br /> Owner's Name Gordon Kost Address same Phone — <br /> Conlractor Clark Well Address 2024 E. Charter License No,371 560 Phone462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONKM Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 <br /> (I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> Lj Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications <br /> M Public 1:7 Other p Delta Depth of Grout Seal Type of Grout J <br /> CI Ifriomion ­Approx. Depth ❑ Eastern Surface Seal installed by (� <br /> Repair Work Done U Type of Pump _ H.P, State Work Done_ J <br /> Well Destruction 0 Well Diameter 6 Sealing Material i Depth f i T 1' t7i f-h A sack wand & cementr <br /> Depth _380 r Filler Material i Depth ErQm. #e 4—O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 71 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.l <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 FLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No, S Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line C <br /> DISPOSAL PONDS ❑ <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 she.. not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor' hiring or-subvcMracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persorti subject to workman's compensa- <br /> tion laws of California." <br /> The applicant s a f r al rs utred inspections. Complete drawing on reverse side. <br /> Title:Signed ; • VP Clark Well In <br /> * -_ T sat.: 25 Jan. <br /> FIR DEPARTMENT USE ONLY <br /> � .,�� �f �Z <br /> Application Accepted by .�- °"��*g_"e.,t'��.....`. Date atm ��] �. Area <br /> Pit or Grout Inspection by Date Final Inspection by 1` 11 d Date — <br /> Additional Comments: <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH (RECEIVED 9Y ��}DAAT�E�/ry7 r PERMIT NO. <br /> • EH 1]•7<t IREV.I/rsl I .Ot3 �� ! I I Q �Tv� !1 f -010 <br /> EH 114.26 �^' <br />