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APPLICATION , f <br /> PAYMENT , SAH JOAQUIN COUNTY PUBLIC HEALTH SR <br /> ENVIRONMENTAL HEALTH DIVISI6 A, <br /> RECEIVED 445 N SAN JOAQUIN,PHONE(209)4694 D# F <br /> � 9� -P O BOX 388,STOCKTON,CA 95201-0 8' /�cc# <br /> r t '' :,�T PERMIT EXPIRES 1 YEAR FROM DA EI55II <br /> SAN JOA{�l3t.t L.f,,.I!.Y _. <br /> PUBLIC HEALTH,,`:-i VICES (Complete .in Txiplical: )' N V# <br /> ENVIRONWIENTAL t-&.Llti DiVI'SION .1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is n <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of Sail Joaquin County Public Health Services. <br /> Job Address 200 N. BECKMAN ROAD City - 1LODI Lot Size/Acreage APPROX. 1 ACRE <br /> fl <br /> SAN JOAQUIN COUNTY MOSQUITO I1 - <br /> Owner's Name AND VECTOR CONTROL DISTRICT Address 7759 S. AIRPORT�,WAY, STOCKTON, CA phone (209) 982-4675 " <br /> 3241 FITZGERALD ROAD, SUITE 2 <br /> TURNER EXPLORATION RANCHO CORDOVA, CA 95742 0602720 (916) 852-7454 l <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C'1 DESTRUCTION_M Out of Service Well 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR nSOIL BORINGS OTHER 191 . Monitoring Well .C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK >�r SEWER LINES ?501 :DISPOSAL FLD. !SD' PROP. LINE 7501 <br /> FOUNDATION 30r AGRICULTURE WELL 50r !!OTHER WELL 5r PITS/SUMPS 7501 <br /> INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS DRILL 4° SOIL BORINGS TO 601 <br /> C7 industrial ❑ Open Bottom a Manteca Dia. of Wall Excavat on Dia. of Well Casing NA <br /> n Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ i' NA Specifications NA <br /> 1'I Public (-I Other 0 Delta Depth of Grout Sear NA Type of Grout NA. <br /> f I Irrigation Approx. Depth I I Eastern Surface Seal Installad by NA <br /> Repair Work Done 0 Type of Pump H.P, IState3,Work Done 16 SURFACE <br /> 4-INC:-II Sealing Material i Depth; 5% BENTONITE GROW <br /> Wei! Destruction )(3 We!! Diameter , <br /> Depth _� 50-FEET Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' l REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sftvw is <br /> NA i :available within 204 feet.} " <br /> Installation will serve: Residence_____ Commercial— Other I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: �' "`' Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity I' F No. Compartments <br /> PKG. TREATMENT PLT.0 { Method of 0*s eisai <br /> Distance to nearest Well Foundation Property Lina <br /> LEACHING LINE NA Cl Na. f3 Length of fines li Total Idngth/size ' v <br /> FILTER BED 0 Distance to nearest Well Foundation Ij °'Property Lina <br /> I, Number <br /> SEEPAGE PITS 11 Depth Sire J <br /> NA 53 --A-- <br /> SUMPS <br /> LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cavity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanessysuw taws. and <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the perfotmance of the work for which this permilt Ii i*sued,I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California:" Contractors hiring or sub-con ersetinQ signature <br /> certifies the following: -I certify that in the pertorrimocs of the work for which this permit is iiwed,'i shall employ person*subject towaikrtten'aeompensa- <br /> tion laws of California." '' ,r <br /> Theeppiicant calf I it inspections_Compfate drawing on reverse side. <br /> �I. it <br /> REGISTERED GEOLOGIST �t1"' 6/28!94 <br /> Title: Dalt: <br /> Signed X o II r <br /> EPARTMENT USE ONLY. / ;?�:'="; t:: <br /> ay.. <br /> ApplicationAccepted <br /> I, Dact <br /> Pfd Ace ted ep b Y �.�a.•a:,, ..,+.��: <br /> I� Date <br /> 1 <br /> Pit or Grout Inspection by Data inal Inspection ayoa <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County aPublic Health saviour <br /> EavironmcntaHealth Perini/Servics <br /> 445 <br /> O r <br /> t " <br /> N.San Joaquin.P.O.Bolt 368.Stockton.CA 95201-0388Vil -� a <br /> FEE DATE PERMIT NO. 1_ r <br /> AMOUNT DUE AlrtOtJN7 REMITTED RECEIVED By .11 xZ;^-" <br /> INFO CAS F ..;Y('��Y�.", <br /> EN 13-24(REV.1,"5) S9�_o0 �l./ V r'� •�3�GY ' �.� � V � <br /> F}S 11.7a <br /> �� <br />