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r APPLICATION FOR PERMIT ' SA JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 yl-6 i P O SOX 2009, STOCKTON, CA 95201 Xa PERMIT EXPIRES 3 YEAR—FROM DATE_ I, S.SUUED (Complete in-Triplicate) Application is hereby made to San Joaquin County for a permit to conetr�tt_nn cd/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 aired 1&62 and the Rules and Regulations of San Joaquin County Public Health Services. =� Job Address MORSE RD.-800' E. of Hwy 99 Frontage City LODI Lot Size/Acreage Owner's Name T R T T R U C K I,N G Address 1 1 3 9 6 N. H W Y 9 9 L O D I Phone 931 -6000_ Contractor hFNNTNGS BROS_ DRILL_ Address 3525 PELANDALE AVE- License No. 290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL CX WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ n /a SEWER LINES 0 Z a DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 20 Dia. of Well Casing 10" 1:1 Domestic/Private KI Gravel Pack ❑ Tracy Type of Casing R V r Specifications- I64SC f1 FI Public 1:1 Other Cl Delta Depth of Grout Seal 50 1 Type of Grout BENTONITE a I X Irrigation _Approx. Depth I I Eastern Surface Seal installed by H E N N I N G S B R O S.D R_I L L I N G Repair Work Done - U Type of Pump H.P. State Work Done_ V] Well Destruction D Well Diameter Sealing Material it, Depth Depth Filler Material A Depth � f TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION ( I INo septic system permitted if public sewer is # available within 200 feet.) i 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. .❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total Wrf§ i/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number • SUMPS LI Distance to runt: 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- tion laws of California." The applicant must call for all required inspections. Complete draw g On reverse side. • signed x t�QM�11, 1°fi1 • ,� Titl Date: N 0 V . 9 , 1992 tl FO IAEP ATMENT USE ONLY Application Accepted by _—__ __ �Onr.R\ Date ` � Area `� Pit w/(irotrt Inspection by DatefZ Final Inspection by_ � ate -1,�SZ Addhbnal/al Commence: ,J Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEPERMIT'NO. . EM 1341(REV.r i Pis) O'J , D;o 3-0" A 0-- f 1 to-72- QOf, EK 11-m