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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 pEgN T T EXPIRES 1 YEAR PROM DATE ISSUED (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 in 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 23755 N. Devries CityLodi Lot Size/Acreage 85 acres Herb Goehring 6353 E. Harney 368-4173 Owner's Name Address Phone Contractor Clark Well , Inc. Address 2024 E. Charter Way License No. 371560 Phone 4627676 TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ Monitoring Well PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK 90 , SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LZD r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6— 5/8" M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing }{ Type of Casin Steel Specifications 41 0 �) Domestic/Private �?�Gravel Pack ❑ Tracy g Q Public I-1 Other ❑ Delta Depth of Grout Seal 100 r Type of GroutRtnnfoni te MI Irrioauon Approx. Depth ❑ Eastern Surface Seal Installed by Clark Repair Work Done U Type of Pump Sub H.P. 1 . 5 State Work Done install (� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 8 Depth rtr TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION ED DESTRUCTION CI INo septic system permitted it public sewer is U 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line �1 LEACHING LINE 0 No. & Length of lines _ Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number I SUMPS LI Distance to nearest: Well Foundation Property Line r� DISPOSAL PONDS ❑ 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 California." The applicant u c f II e i s do Complete drawing on reverse side. Signed Title: VP Clark Well r Inc oats: 1 /14/91 FPR7DERTMENT USE ONLY �} Application Accepted by C''' a ^ ^�^ Date ` 11 Area PitoGrou Inspection by" V, c� Date , 1 Final Inspection by ` �— Date Additional Comments: r '`^A L`^�Q "`"'� �� — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH C EH 13-21 MEV.I/n 51 rl L r O�( 1 ` —`�� 1 I— oil EH,1.2e A