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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY. PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R ORQM DATE ISSUED (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 15405 Locust Tree Rd city Lodi Lot Size/Acreage 45 acres Owner's Name Ben GoeHfring Address same Phone 333-053 ConlractorClark Well, Inc Address 2024 E. Charter License No. 37150Phone - 676 TYPE OF WELL/PUMP: NEW WELL$kf WELL REPLACEMENT M DESTRUCTION ❑ Out of service Well 0 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well E7 DISTANCE TO NEAREST: SEPTIC TANK }12 5 r SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL +1 00 r PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZU Dia. of Well Casing 12 ' LJ Domestic/Private X6 Gravel Pack C] Tracy Type of Casing Steel Specifications �cM Public I'1 Other ❑ Delta Depth of Grout Seal 50 r Type of Grout,. sack X GXlrriUation Approx. Depth 0 Eastern Surface Seal Installed by Clark Repair Work Done 0 Type of Pump sub H.P. 30 State Work Done _insta I I Weil Destruction © Well Diameter Sealing Material i Depth Depth Piller Material t± Depth TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIWADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of $oil to a depth of 3 feet: Water table depth tj SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments p PKG, TREATMENT PLT, ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI 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 wori�man's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pertormance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion taws of Gaff ia.' The applicant u r uir d ins c m lets drawing on reverse side. Signed Title., VP Clark Well, Inc Date: 8-)Mar 91 FOR DEPARTMENT USE ONLY es j Z Application Accepted by bate � l � Area Pit ci� rVi4hspsction by r pate l Final Inspection by Data !. Additional Comments: 3�0 'Arl. J S-Z Applicant - Return all copies to: SAN JOAQUIN COUNTY PU LICwH ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 Box 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RE ,V�ED BY DATE PERMIT NO. / CtE� • EH 13.24IREV.iIn5) t 3 �C7� ,/y---kc� t;H i�•2e ✓ r 1 f L