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APPLICATION SAN 9AQUIN COUNTY PUBLIC HEALTH &VICES ENVIRONMENTAL HEALTH DIVISION "` ' ' 445 N SAN JOAQUIN, PHONE (209)468-3 P O BOX 2009, STOCKTON, CA 95201 n _ x' 22 PERMIT QMIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f Application in hereby made to San Joaquin County for a permit to construct and/or install theworkherein describe . application is pdahmyabdeiginy�ecapllmce with� San Joaquin County Ordinance No. 51,9 and 1862 and the Rule Joaquin County J8tai€y 11.e11evron a tions of San Job Address 6421 W. Paddock Place cityLodi `ln , Owner's Name Flag City Inc . Address P 0. Box 2180Lodi } e1 Phone - Contractor Spectrum Explorat4pss 2825 E. Myrtle StreEL�ense No. 512268 Phone 465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)C /((�1�nitoring Well DISTANCE TO NEAREST: SEPTIC TANK _I--`�� SEWER LINES ± 15V DISPOSAL FLD. PROP&PIM Boriff S FOUNDATION +57D AGRICULTURE WELL -t-S-D _ OTHER WELL 2110r PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w du ❑ Industrial CTO It Bottom ❑ Manteca Dia. of Well Excavation 2" Dia. of Well Casing Man- F.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications I'1 Public 25her rl Delta Depth of Grout Seal X0e, * Type of Grout bent/ceme t I I Irrigation _Approx, Depth I I Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public waver is available within 200 feet.) inS[aiiatinn will Iarva�Resitlericn_ �drnT..Si ti:: ^,^,_: Number Of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size (t FILTER BED ❑ Distance to nearest: Well Foundation Property Line rli1VL� SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line I_ DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state rules and ragulations of the San Joaquin County laws, and Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I she nor employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature eertifies the i : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's companw- tion la I CalifoIn The ap licant must 11 for all req ed i cti pl drawing on reverse side. Signed itle: __ Manager Date: 8-31-94 FOR DEPARTMENT USE ONLY ((�/ Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by c � Date Additional Comments: Z %AO k/ Applicant - Return all copies to: San Joaquin C unty Public Health ServicesD Environmental Health Permlt/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO �J H RECEIVED BY DATE PERMIT NO. l�� 1