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:k APPLICATION FOR PERMIT SAN JQAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �I P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 !I II° Y R ` (Complete in Triplicate) Application is hereby made to San Joaquin County for a persit to construct and/or install the work herein described. This application is Mode in cowpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Saar Joaquin County Public Health Services. Job Address 23755 N. De'vries CityLodi Lot Size/Acreage 85 acres Herb Goehrillg 6353 E. Harney Phone 368-4173 Owner's Name Address .1 1 Contractor Clark Well, Inc. Address 2024 E. Charter Way License No. 371 560 Phone 4627676 TYPE Of WELLIPUMP: NEW WELD WELL REPLACEMENT P_ DESTRUCTION D Out of Service Well Cl PUMP INSTALLATIONXff SYSTEM REPAIR ❑ OTHER 0 Monitoring well Ll } DISTANCE TO NEAREST: SEPTIC TANK 9 0 r SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1_U r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _65/81- M Industrial O Open Bottom C] Manteca Die. of Well Excavation Dia. of Well Casing XEJ Domestic/Private �tNravel Pack .❑ Tracy Type of CasingSteel Specifications IQ Public I. Other I! D Delta Depth of Grout Seal �_�.�....• Type of G►ou C.I Irrigation _ _ Approx. Depth ❑ Eastern Surface Soul Installed by Clark Repair Work Done ' 0 Type of Pump Sub H.P. 1 • 5 State Work Done install 13 Well Destruction ❑ Well Diameter Sealing Material i Depth Jr Depth it Filler Material A Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAtR/ADDITION 0 DESTRUCTION EJ INo septic system permitted if public.sewer is :I available within 200 feet.) C ' Installation will serve: Residence E Commercial— Other V ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ n Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance,to nearest: Well Foundation Property Line i q SEEPAGE PITS 11 Depth iJ Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ,n I DISPOSAL PONDS ❑ I V, 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 raguiations of the San Joaquin County I ' 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 employ any person in such manner as t0 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." !! 4 The applicant usil. c f II e s do Complete drawing on reverse side. Signed Title: VP Clark We 11, Inc Data: 1 /14/91 II F R TMENT USE ONLY a� J Application Accepted by . �""^ Date ^_�:�1 1 I-- Area pit Grou Inspection by Final Inspection b Data Additional Comments: .7 t, — ii Applicant — Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7— it ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JoagUIN, P O BOX 2009, 3TOCKTON, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY DATE PERMIT'NO. INFO CASH . tH ,a•z4IREV,,insl r0-r QM i�•ZE I- o t3