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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 '.KI JOB NO. <br /> P O BOX 2009, STOCKTON, CA 95201 20-3693-01.001 <br /> `TD L+(16- <br /> 16- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> /awl <br /> �/ amplete in Triplicate) <br /> Application Is hereby'+made to San Joaqu n C ty for a permit to construct and/or install the work herein described. This <br /> application is made in ccupliance 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 White Slough Water Polution Control Fac. City Lodi, CA Lot Size/Acreage <br /> City of Lodi Address Call Box 3002, Lodi, CA 95241 Phone <br /> Owner's Name <br /> Contractor Spectrum/KleinfelderAddress 2825 E.MYRTLE ST. License No. 512268 Phone 948-1345 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ f�f �R+}£�ff3i�t�6i*treg'Sesw ee-ge3 -'� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XK }tO 1 v <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -P op.-LTNE —LL-70' Dee <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -Pi3t3ttiuFPS 12 Borings <br /> iameter <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- -Dia-af-waft-'ashen <br /> F.) Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ -Sperificat= \ <br /> I"1 Public l] Other fl Delta Depth of Grout Seal -TTpwvf <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by or use hole plug to <br /> Repair Work Done 0 Type of Pump H.P. State Work Done till. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth n <br /> Depth Filler Material & Depth V4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 INo 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 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 ❑ <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 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 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- <br /> tion laws of Califor <br /> The applicant m t II r all aqui ed in cti eta drawing on reverse side. <br /> Signed X Title: Project Engineer Date: 12-23-92 <br /> FOR DEP TMENT USE ONLY <br /> Application Accepted by Data - Area �/ <br /> Pit or Grout Inspection byDate Final Inspection by Date,41 a q 3 <br /> Additional Comments: CC t <br /> Applicant - Return all copies to: San Joaquin County Public Hea Services <br /> Environmental Health Permit/Services .tl <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY 2AT9 PERMIT'NO. <br /> INFO <br /> . EH 13 24 iREV.1/"5) <br /> ✓� V C �� Q� �`� !// J r� <br /> EH 74.26 <br /> y, \ <br />