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APPLICATION PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH S RIS" ENVIRONMENTAL HEALTH DIVISIO RECEIVED 445 N SAN JOAQUIN,PHONE(209)469- 4EOiD# J U N 3 01994 P O BOX 388,STOCKTON,CA 95201-0 8 c SAN JOAQUIN' ��`-'•�I T Y PERMIT EXPIRES 1 YEAR FROM DA E IS'SII PUBLIC HF t_ ;' ,;�,t ViOES (Complete in Triplicat ) INV # ENVIRON,ViENT AL H1;3 IV]SION Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is an Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 200 N. BECKMAN ROAD City _LODI Lot Size/Acreage APPROX. 1 ACRE SAN JOAQUIN COUNTY MOSQUITO Owner's Name AND VECTOR CONTROL DISTRICT Address 7759 S. AIRPORT WAY, STOCKTON, CA Phone (209) 982-4675 3241 FITZGERALD ROAD, SUITE 2 Contractor Address EXPLORATION Address RANCHO CORDOVA, CA 95742 License No. Phone Phone (916) 852-7454 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1.1 DESTRUCTION M Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑SOIL BORINGS OTHER M Monitoring well (3 DISTANCE TO NEAREST: SEPTIC TANK >501 SEWER LINES >501 DISPOSAL FLD. 7501 PROP. LINE X501 FOUNDATION 301 AGRICULTURE WELL 7 501 OTHER WELL 51 PITS/SUMPS 7501 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS DRILL 4 SOIL BORINGS TO 601. C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing NA l] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ NA Specifications NA I') Public i-1 Other n Delta Depth al Grout Seal NA Type of Grout NA I i Irrigation —Approx. Depth I I Eastern Surface Seal installed by NA Repair Work Done U Type of Pump H.P. State Work Dona Well Destruction )13 Well Diameter 4-INCH Sealing Material i Depth 591 BENTON I TE GR] Depth _ 50-FEET Piller Material i Depth —41 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is NA available within 200 feet.) Installation will serve: Residence— Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE NA L1 No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaatron Property Line SEEPAGE PITS NAI I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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 shell not employ any person in such manner as to become subject to workmen's compensation taws 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." The applicant all If it inspections. Complete drawing on reverse side. Signed)I Title: REGISTERED GEOLOGIST Date: 6/28/94 EPARTMENT USE ONLY Application Accepted by Date rep. Pit or Grout Inspection by D e final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permil/Services7 r 0s 40 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 ve^� FEE AMOUNT DUE AMOUNT REMIT7E0 RECEIVED BY GATE PERMIT'N0. M INFO /r] ��CgA]S�g O yy . EriU24IREv,Fins) �b.00 �� C!!'VO `�G�— l � a EH 11.21