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I <br /> APPLICATION FOR PERMIT <br /> k <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YAM FROM DATE ISSUR <br /> (Complete in Triplicate) <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 San 4 <br /> Joaquin County Public Health Services. <br /> Jab Address 1100 N . Ham <br /> ' City Lodi Lot size/Acreage 4 <br /> 9 <br /> ' - 221 West Pine Phone 333-6706 <br /> Owner's Name Cit o f Lodi ' Address <br /> + <br /> Contractor <br /> Clark Well. Address . 2024 E . CH�ar. tPr WaSbcense.No.3T1-560 Phone462-7676 <br /> TYPE Of WELL/PUMP: - � NEW WELL ❑•� WELL REPLACEMENT ('l Out DESTRUCTION CI o! Service Well 0 <br /> Monitoring Well <br /> PUMP INSTALLATION ElSYSTEM REPAIR © Test W e PfHER , <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES ----- <br /> DISPOSAL fLD. PROP. LINE ! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ Dia. of Well Casing s <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Weii Excavation._ Specifications- <br /> 171 <br /> pec;tications,. <br /> C ❑ Type of Casing- <br /> 1 Domestic!Private <br /> Grave! Pack ❑ Tracy Type of Grout <br /> I'1 Public Ia Other Cl Delta Depth of Grout Seal <br /> I I Irrigation _.._.Approx.:Depth I I Eastern Surface Seal Installed by <br /> of Pump, H.P. State Work Dona <br /> Repair Work Done tl Type Sealing Material a Depth <br /> Well Destruction D Well Diameter r <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRlADDITIgN I I DESTRUCTION i I avail bleuc sys.em within 200lost1�ed if public saver is <br /> Installation will serve: Residence Commercial^ Other <br /> Number of Ihring units: Number of bedrooms <br /> Water table depth <br /> Character of soN to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK 0�--Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT.0 <br /> Distance_to nearest: Well Foundation - Property Line <br /> LEACHING LINE ❑ . No. 6 Length of lines Total length/sire <br /> FILTER BED D Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 -Depth Size Number <br /> i SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> lt be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work wi <br /> rules and regulations of the Sen 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 subcontracting signature <br /> certifies the following:"I unity the performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of Californ <br /> The applicant I r req i in c C eta drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> 11 MarcbQ3 <br /> DEPARTMENT 135E ONLY c <br /> oat <br /> Application <br /> F Application Accepted by 3Ib �a urea/ cct <br /> I Pit or Grout Inspection by <br /> Date_ Final Inspection y <br /> I Additional Comments: th <br /> 4 <br /> Applicant - Return all copies to: unty Public HeRl <br /> EnvironmentalJoaquin oHealth Permit/Services <br /> Vices <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEkPERMiT'NO. <br /> r <br /> INFO <br /> IAEY•rien O. , p <br /> EM 14-21e .O <br />