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} <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN jOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX. 2009, STOCKTTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> f (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the vork herein described_ This <br /> application is made in caWliance vlth San Joaquin County Ordinance No. 51+9 dad 1862 and the Rules and Regulatione of San <br /> Joaquin County Public Health Services. <br /> 31r�" <br /> .lob Address _ 3 D 4 9 W . ! H i a h til ay 12 _ City Lodi Lot Size/Acreage <br /> Owner's Nams Surendra F . Patel Address 607 SO .' Cherokee Phons209-368-1152 <br /> P . O . Box 950 209- <br /> 1 ContractorO i 1 E q u i p m n t S er V -Address San Andreas License No. 3 2 3 417 Phone754-1808 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ " WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service !fell C1 <br />? PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XXrocto;ing well C <br /> s sot wring <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wed Excavation Dia. of Well Casing <br /> C-1 Domestic!Private ❑ Graved Pack ❑ Tracy 'Type of Casing Specifications <br /> 11 Public C1 Other f"1 Delta Depth of Grout Seal Type at Grout <br /> I I Irrigation ! .Approx. Depth I I Eastern, I Surface Semi Installed by <br /> Repair Work Done 0 Type at Pump'; H.P. State Work Done <br /> Wed Destruction ❑ Wed Diarnecer Sealing Material i Depth cPmPslt/bentonite — 20 <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I I DESTRUCTION I I IND septic system permitted it public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residents Commercial Other <br /> Number of riving units: Number of bedrooms <br /> t; <br /> Character of soil to a depth of 3 feet: '} Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to.nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to rearem: Weil Foundation Property Line <br /> DISPOSAL PONDS ❑ ?` <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances• stats laws, and <br /> rules and rapuiations of the San Joaquin°County <br /> i Home owner or licensed agent's signature aertitiea the following: "I cartify that in the perlorrhanca of the work far"which this permit is iswed, f shall nor <br /> employ any person in such manner as to become wbiect to work man•s;compensation laws of California.- Contractors hiring or subcontracting signature <br /> terrifies the following- "1 certify that in the psrfortwWWA of the work for which this permit is isaued. I shall employ <br /> tion laws of am <br /> P Y persona wbjecr to workman's campensa• <br /> The apps• nt ca for tions. Complete drawing"an reverse side. <br /> Signed '" Title: Pres . -Oil Equipment <br /> Data 11/2/93 <br /> ith A , al lin Service <br /> FOR OEPA'RTMENT USE ONLY5 . <br /> • <br /> Application Accepted by Date Arse # <br /> Pft or Grout Inspection b Onto" <br /> Y �-�-- Date Final tnspection by <br /> Additional Comments: <br /> Applicant - Return all copies:to: San Joaquin County Public Health Services .. <br /> Environmental Health Permit/Servicies <br /> 445 N San Joaquin, P O Box 2008, Stkn• CA 95201 <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTEDASN RECEIVED BY GATE PEANUT,No. <br /> • EN 13.24(REV.Iia61 �M� <br /> EN 1424 '.�',' <br />