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APPLICATION FOR PERMIT <br /> SAN J aWUIN COUNTY PUBLIC HEALTH SERVICES <br /> + ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> i. RXIRMITEXPIRES I YEAR FR M D TE ED <br /> (Complete in Triplicate) ff dav <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance, with San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of a <br />{ Joaquin County Public Health Services. gu San <br /> 4 Job Address 1 /4 mile east.IHWy 99 & Turner RdC;ty Lodi Lot Size/Acreage <br /> Owner's Name City of Lodi 221 West Pine <br /> Address Phone3 3 3-6 7 0 6 <br /> Contractor Clark Well InC Address 2024 E. Charter License N0.371 560 Phone4 <br /> TYPE OF WELL/PUMP: NEW <br /> WELL ❑ <br /> WELL REPLACEMENT C.1 DESTRUCTION ❑ Out of Service Well ❑ <br /> Test Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ OPen Bottom <br /> ❑ Manteca Dia. of Well Excavation_- }�� Dia. of Well Casing <br /> I l Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing <br /> �'�ublic I Specitications�. <br /> !-1 Other _ 17 Delta Depth of Grout Seal <br /> t I IrrigationApprox. Type of Grout <br /> 500 L Depth { I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H p <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth t <br /> P »T�tP_ mAr-t_ TaTci i <br /> Will either be' <br /> Depth Filler Material & bepthreemed or abandoned fter test. <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I i REPAIR/ADDITION I I� DESTRUCTION 11 1 is � <br /> e <br /> e it 'r r war \ Y+ <br /> Installation will serve: Residence I Commercial_ Other available within 200 feet.l 9 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: (y4 <br /> SEPTIC TANK- p Water table depth 1 7 f <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl ._r-- <br /> Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> r� <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER VIED Cl Distance t6 nearest. Wall Foundation <br /> ' Property Line <br /> SEEPAGE PITS Il Depth Size <br /> Number <br /> SUMPS 0 Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ C`( <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, ander", <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 em to <br /> tion laws of California." f p y persons subject to workman's compensa- I <br /> The applicant all r al e i f c ' s plate drawing on reverse side. <br /> Signed X Title:VP Clark Well InC: <br /> Date: !!! <br /> TMENT USE ONLY <br /> l k <br /> Application Accepted by ' Date lit i" Area_ ? <br /> Pit or Grout Inspection by Date Final Inspection by <br /> f Date <br /> Additional Comments: 2C9 <br /> Applicant - Return all copies to: San Joaquin County Public Health , <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT E0CK 9 <br /> INFO ASH RECEIVED BY DATE PERMIT-NO.EH Q-24 IREV,iiKsj <br /> , <br /> t <br /> EH A-25 B <br /> R <br />