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APPLICATION 'SAN JOAQUIN COUNTY PUHLIC HTH SERVICES ENVIBANMM TAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCSTON, CA 95201 p1gMIT EMPIRES 1 DATE ISSUED (Complete is Triplicize) Application is herebyi.ade•to s,, Joaquin county for a permit to couatrucs aadJor install the vorY herein described. Thus application is made in coM1111mce v'tLb Sea Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Josquin County Public'Sealth service*- 3049 W'. HWY ,I2 City Lodi Lot Size/Acreage Job Address Sonny Patel Address Phone Owr»rs Name 3663 Omec Circle #8 916 Contractor B & F Drilling Address Rancho Cordova , CA Lill", Ivo. 514428 Phone 631-9546 ,. e WELL REPLACEMENT ❑ DESTRUCTION ❑ Out: of Service Well ❑ TYPE OF wELL/PUMP: � NEW WELL ❑ 16cultoring tie].) C]�y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Soil Boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -----------. DISPOSAL FLO. PROP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Indu mai O Open Bonorn ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Peek ❑ Tracy Type of Caskv Sperafir�tiorts I-] Public n Other n Delta Depth of Grwt Seal Type of Grew I I Irrigation Approx. Depth I I Eastern Surlace Sent Installed by Repair wort DoD Type of Pump H.P. Stals Work Dona ne r Weft Destruction ❑ Well Diarrmter 9aaLizi; Material i Depth �IR1-n L-/13P n t ri n i T P = 15 Pillar Material i Depth- N/A Depth — + TYPE OF SEPTIC WORK:1 NEW INSTALLATION I I REPAIA/ApOITION 1 k DESTRUCTION I I INo septic system pemunad it public ttewsr is available within 2W last.) Installation will serve: Residehoa C rimercial_ Orher Nwnbw of living uniq: Number of bedrooms Chwactw of soil to a depth of 3 fait: Water table depth SEPTIC TANK ❑ Type/mfg Caoacrty No. Compartment@ PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. 6 Length of lir►es Total length/size [ FILTER BED © Distance to nearest_ Well Foundation Property Line SEEPAGE PITS I I Depth Siwe Numom SUMPS LI Distance to nearest: WON Foundation Property Line DISPOSAL PONDS O I#teteby certify that I haw prapsrsd this application and that the wort will be done in accordance with San Joaquin county ordinances, state Laws."a ruin and regulations of the San Ja&6,6in County Home owner or licensed agent's""ture eeftffiot the following: ".1 ceft'ty that in the parfbmwnce of the work far which this pem-at is •tasued. I shall i 0 cloy shy owson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signati esnifies the following: "I certify that in the performance of the work for which this permit wiaausd.I mall amolay persons subject'to workman's compare tion laws of CaNfomia.- '1 , The aoplicart t tali For all insaretions mplsa drawing aids. P SgreOd Title: Data: P FOR DEPARTMENT USE ONLY Applirstion Accepted by Date At" Pit or Grout Inspection by Date Final InspecOon by Data Additional Comments: ' Applicant - Return all copies to: San Joapuita County Public Hes.l�th Services Environmental Health Permit/Services 445 N.Saa Joaquin, P2009, StYn, CA 95201 FEE INFO .AMOUNT DUE AMOUNT /C11 k.C,K�H RECEIVED SY rOATS PERMrT'No.