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APPLICATION <br /> * I <br /> YAK JOAQIIIN. COIINTY PUBLIC SEBYICTS - <br /> ffi�IEORI[ffiITAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, ..STOCgTON, CA 95201 <br /> FRY7T E%P_IRES i YEAR FROM 'bD TE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sail Joaquin Countp for s permit to cc=truct:%nd/cr install the wort herein described This <br /> sgylicatios is made vith Sim Joaquin County Ordinsnce So' 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services_ <br /> 3049 W.! HWY 1'2Lodi. Lai size/Acreage <br /> Job AddressCity <br /> Sonny Patel. Address - Phone <br /> Owner's Name 3663. Omec Circle #8 916 <br /> Contractor B & F Drillir'ig Address Rancho Cordova , CA License No. 519428 Phone 631-9546 <br /> TYPE OF WELL/PUMP: ;NEW WELL ❑ WELL REPLACEMENT Ci DESTRUCTION ❑ Out of service Well ❑ <br /> ;..�. lbnitorizs�yell ❑ <br /> PUMP INSTALLATION ❑- SYSTEM REPAIR OTHER Soil Boring <br /> i DISTANCE TO NEAREST:1SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> (FOUNDATION AGRICULTURE WELL _'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELL PROBLEM AREki CONSTRUCTION SPECIFICATIONS <br /> M bukatnal ❑ Open Bonorn ❑ Manteca Dia. of Wali Excavation Dia. of Wap Casing <br /> M Dornestic/Private ❑ Gravaf PacA* ❑ Tracy Type of Caw+Q Specifications <br /> I'1 Public n Other rl Dela Depth of Grout Seal: Type of Gran <br /> I I Inipation ;',_Approx. Depth I I Eastern- Surface Seal Installed by <br /> " State Work Done <br /> Repair Work Done C7 Type o. Ptiixip N.P. , <br /> Wed Destruction p Well Diartrter <br /> sealing liateriil i depth' ('.a rr a n t /R P n f n n l t ps = 15 <br /> Depth ': Tiller Ifiaterial i Depth H�A _ <br /> TYPE OF SEPTIC WORT(: :'NEW INSTALLATION I I REPAIR/ApOITION I I DESTRUCTION I i INo septic system perrnitted if public sewer is <br /> availtble within=01040 <br /> t <br /> Installation will serve: Residenceria'. Caeeatercisl_ Other <br /> Number of living Units i Number of bedrooms <br /> Character of sots to a depth of 3 fart:. Water table depth <br /> SEPTIC TANK. ❑ Typelt►rfq Capscitlr No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Dispo"I <br /> Dkstsncs'to nesresc Wall Foundation Property Lina <br /> LEACHING LINE C7 No. 6 Length of linea '"Total length/size <br /> FILTER SED ❑ Distanca'to nssrazz Well J Foundauon Property Line, <br /> SEEPAGE PITS Ii Depth Sims Number <br /> SUMPS Ll Distance to neresc WON Foundation Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I he"prepsrad the appix=on and that the work will be done in accordance with San Joapuin county ordinances, stats flaws. and <br /> rules and regulatwna of the San Jawuin couaw <br /> Meats owner or lipnsed agent's wgnaaire cer•hfwe;the following: "I'certify that in the pardarrnance of the work for which this permit is issued. 1 snap"i <br /> arrtploy arty person in such rnanner as to beccrns subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> tatrt ins the fagowwirtg:"I OMIW that in''ura perfonrwnca of the work for which this permit is iBaued.I shall amplay parsons Subject to worknon's cornpanaa• <br /> tion laws of Capfomis." s <br /> ::96can t tali for;aN repuirso inspections, mplem drawing side.Title: Oats: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dan Area <br /> 5 <br /> Pit or Grout Inspection by Date Final Inavection by Dam <br /> Additional Comrnenu: f <br /> Applicant - Return all copies to: San Joaquin Couotg Public health Services <br /> Environsiental Realtb Permit/Services <br /> 445 N Sea Joaqullf. P 2049, Stkn, CA 95201 <br /> FEE .AMOUNT DUiF, AMOUNT REMITTED Clt ►t RECENED dr 0ArE PERMIT'610. <br /> l <br /> 7/1 <br /> L3 <br /> Err t� 1 j5(/ i� <br />