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APPL I CATION See Attacher ,° Diagram�5�1 SAN JOAQUIN COUNTY PUBLIC HEAL+H SERVICES c, JJ ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Vi,µ � T (Complete in Triplicate) App 11Jj!PAr.by made to Joaquin County for a permit to construct and/or install the work herein described. This applicntion 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. dab Address Lockeford Wastewater Treatment Plant CityLockeford Lot Size/Acreage See Attached Owner's Name Lockeford CommunityAddress P.O. Box Drawer Z Phone (209) 727-5035 Services Istrlct Contractor WESTEX AddressP•O• 1664 W. SacramentOLicense No.532Jaa -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service W Monitoring Well b PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NA PROP. LINE See Attache DISTANCE TO NEAREST: SEPTIC TANK NA - SEWER LINES NA DISPOSAL FLD. -FQUNDATION _219-0-O0 AGRICULTURE WELL 7500 OTHER WELL 7500 PITS/sumps NA J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I n Industrial 0 Open Bottom ❑ Manteca Dia. of Welk Excavation PVC 0 Dia. of Well Casing 411 i t.1 Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing_ Specifications SCh 93' Type of Grout Cement) I'I Public Cl Other ❑ Delta Depth of Grout Seal WESTEX en Onl e I I trrigation _ Approx. Depth I I Eastern Surface Seal Installed by ws Repair Work Done U Type of Pump H.P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth .5. - Filler Material A Depth 1 ! TYPE OF SEPTIC,VVORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ffJ�'s�ptic system permitted it public sewer is � �4 raJiilable within 200 feet.) Installation will serve: Residence Commercial_ Other i4 Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity '` q, 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 13- Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS 11 Depth Size Number ESUMPS LI Distance to nearest: Welt 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 co.ty.joid nances; 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 issiied,-1 shaH not ( employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sdt=contracting,signaturs { certifies the following: "I certify that-in the performance of the work for which this permit is issued, I shall employ persons subject to wiiikman's compensa= - tion laws of California." %'» I The applicant so c4or oil required inspecyic s. Co lete drawing on reverse side. ,� �7 ' A Zr � ' ")Z S � Date: ,�1-14-��'" Signed Xr Title: t� R PARTMENT USE ONLY C Application Accepted by ' Date_ -- Area Pit or Grout Inspection by Date Final Inspection bData Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services � , �-9;c 445 N San Joaquin, P O Box 2009, Stkn, CA 95201' '� «0.: E4ft AMOUNT DUE AMOUNT REMIT, D CRECEIVED BY DATE PERMIT'NO. EH 13.24 IAEV.i/w 51 �V. _