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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIREg 1 YEAR FROM DATE (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City 125 S . Hutchins Street Lodi Lot Size/Acreage City Of Lodi 221 W . Pine Street 333-6706 Owner's Name Address Phone ContfactorClark Well , Inc Address 2024 E . CHarter Way License No.371560 Phone 462-7676 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well 0 PUMP INSTALLATION O SYSTEM REPAIR 0 OTHERX99 Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. PR�PA&Ef.50 t FOUNDATION AGRICULTURE WELL OTHER WELL. PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_'1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing N o n e �.l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 4"*Public j 2 5 S XI? NIIPr, h i n s S Ln&`0a Depth of Grout 5eald Type of Grout_ 1 I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done C LTL y Tyjjie"of Pump 1 H.P. r i IState ty+Vork Done _ 3 --67 0 6 Sealing Material & Depth Well Destruction ❑ Well Diameter Deptn ,U Filer t �sali a Dep wh�� r, - 462-767 6 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial _ Other x x '1'e s t Number of living units: Number ollb�0ooms +50 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 8" Method of Disposal Distance to nearest: Well Foundation Property Line x LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ i Distance to nearest: Well Foundation rPropeny Line SEEPAGE PITS 11 Depth Size Number . v. SUMPS ' ' ' Y'LI Distance to nearest: Well µ 1- Foundation Property Line DISPOSAL PONDS O I 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 r t ' ` t i(' Home owner or licensed agent's signature certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, t 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 ormance of the rk for which this permit is issued, I shall employ parsons subject to workman's compensa- tion taws of California." The applicant I for II ins ons t drJIB, ng on reverse side. 'Signed X V P Clark W ell , Inc Date: 22 Jan 92 Trxr��w 1 DEPARTMENT USE ONLY Application Accepted by __-ter W. ►� Date i^ �L-j-9 2 Area 13 Pit or Grout inspection by Date Final Inspection by 1 il 2Gir�.�( __ Data w Additional Comments: Applicant Return all copies to: San Joaquin County Public Health Services, Environmental Environmental Health Permit/Services � f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 EE AMOUNT DUE AMOUNT REMITTED Cg RECEIVED BY DATE PERMIT'NO. INFO CASH �7 (� Ehr 13-2,�. �/Y� EH 14•26 J9 2 1d We 11 , lrlc L4 Jamil