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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 PERMIT EXPIRES 1 YEAR FR M DATE ISSUIM- (Complete in 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3900 East Scottsadle Rd city Lodi Lot Size/Acreage 5 acres Mike Ketelaar same 339-9267 Owner's Name Address Phone Contractor Clark Well , Inc Address 2024 E. Charter License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATIONXX SYSTEM REPAIR C] OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK 150 ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 30 r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQ S 6 5/8 r+ C7 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KM 3bomestic/Private ZIXGravei Pack ❑ Tracy Type of Casing Steel Specifications 7-10 gage I'I Public CI Other FI Delta Depth of Grout Seal 200 Type of Grout 9 sack I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by C l a r k Repair Work Done U Type of Pump Su b H.p. 3 State Work Done _install Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth �Y TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION I f DESTRUCTION i I (No septic system permitted if public sewer is 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size tv FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI Distance to nearest: Well Foundation -. Property Line DISPOSAL PONDS 0 1 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 Ce ifor 'a." The applica u cal o all i e n 1 s. plete drawing on reverse side. Signed x Title: VP Clark Well Dale:1 7 June 91 FOR DEPARTMENT USE ONLY Application Accepted by 0Date �a^ ,.!,.' .•..I_1 Area 13 Pit or Inspection by Date ~2� N al Inspection by D .G /% Additional Commence: Q Applicant Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED By DATE PERMIT ND. . EH73-26(RE V.I/Ms0 ` [/ EH 14-29 � T �