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APPLICATION FOR PERMIT SAN —GAQUIN COUNTY PUBLIC HEALTH 6--�2VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED COPY (Complete in Triplicate) Application In hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This application is astde in c0upliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address 8400 W. Handel Road ,I City Lodi Lot Size/Acreage 6 Y Owner'sName Harvey Properties Lk aaldress 8400 E. Handel Rd. Phone 209-4768530 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Voll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL Y,4 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS cora El Industrial ❑ On Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications I'I Public ❑ Other Il Delta Depth of Grout Seal '�. Type of Grout I I Irrigation _ Approx. Depth [ I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth L7 Depth Piller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat.) Installation will serve: Residence _ Commercial_ Other Number of Going units: _ Number of bedrooms Character of sok to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments /C1 PKG. TREATMENT PLT. ❑ Method of Disposal 1� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin County 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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 compenss tan laws of California." z. The applicantmust 11 aH requked T" wns. Complete drawing on reverse side. Signed -l-!-+r/_-�i�G "t Gf Title:Partner Date: T e FORD ARTMENT USF ONLY o- Application Accepted by �y�� 1 Date n —�J.�j Area - Pit or Grout Inspection by �- Date Final Inspection by _ Dap Additional comments: 1/.t/[// i2 Cti�� it ♦-1�P - y Applicant - Return alI copies San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . Eu u:F racy.rrxs� /��v �Q—(j Zl IS` �-.�� / �-f.3 paTv. FH la aF