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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 EXPIRES 1 YEAR FROM DATE ISEUED (Complete is 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'vith San Joaquin..County Ordinance No. 549 and 1862 and the Rules and Regulations of San , Joaquin County Public Health Services. ~Iq . Job Address 15260 N . Locust Tree Rd City Lodi Lot Size/Acreage 20 acres Larry Nies same Phone 333=1123 _ Owner's Name Address Contractor Clark Well ', Inc . Address 2024 E . Charter Way License No.371560 Phone 462-7676 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)17X DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIOt*:nx SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK +100 } SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ca ng X X[.*Domestic/Private X� Gravel Pack 0 Tracy Type of Casing Specifics VV gage I'I Public CZ Other fl Delta Depth of'Grout Ceal 2 0 0 t Type of Grout 9 Rack---- I ack___I I Irrigation ^._.Approx, Depth I I Eastern Surface Seal Installed by C � Repair Work Done U Type of Pump _ sub H.P. _ 5 _ ..__ State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material & Depth t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiR1ADDITtON 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other C�� 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ 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 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa� n tiara laws of Ca)ifor ia." \1� The applican call t /r i ct, n p drawing on reverse side. t t Signed x Title:V P Clark Well , Inc . Dater May 9 FO PARTMENT USE ONLY Z Application Accepted by Area ' Pit o Grouf spection by �--�—] DateFinal Inspection by f Date77— I Additional Comments: Applicant -- Return all copies to: San Joaquin County is Health Services, Enviro ntal Health Permit/Services . 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 y FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERM11'NO., INFO CASH 3 + EM 13,24 IREV.I/Nsl Ly EH 31.2E �� u