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APPLICATION. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' " ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PO BOX 2009, STOCKTON, CA 95201 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) l l Application is hereby tsade.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 1`6042 E. Baker Lane City Lindell Lot Size/Acreage owner's NameC" & A Lagomarsino Address 16042 E. Baker, Linden Phone Contractpruryiance Drilles,IMorass P.O. Box 64,Linden�_icge No. 377923 Phone 8 8 7— TYPE OF WELL/PUMP: NEW WELL43 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O l PUMP INSTALLATION43 SYSTEM REPAIR 0 OTHER O Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ] Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing Cl Domestic/Private O Gravel Pack O Tracy Type of,Casing_ steel ! Specifications ,18 S I I1 Public Cl 011per n Delta Depth'of;Grout Seal 2 s r 'S Type of GroutGo�cnt 6X Irrigation 512-5 Approx. Depth I I Eastern Surface Seal Installed by G } Repair Work Done U Type of Pump'T'Lrb H.P. 40: State Work Done Well Destruction.. +,O Well Diameter_ Sealing Material & Depth ri ' Depth Piller Material &`Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence Commercial_ Othe'r I Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .Distance to nearest: Well Foundation Property Line LEACHING LINE Q ''No. & Length of lines Total length/size ; FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS O 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 1 Home owner or licensed agent's signature certifies the following: 'Pcertify 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." I -The plicant m it call.f req re inspections. Complete drawing on reverse side. 1 Signed Title: ( n-r-p � rrai a ry Date: C)124-92 FOR DEPARTMENT USE ONLY Application Accepted by Date. `� Area 'WA i Pit or Grout spection by Dated `�- Final Inspection by Date - ® j!Z4 Additional Comments: 3 b L,/ r O �wsEY� Applicant - Return all copies to: San Joaquin County Public Health Services u`LlY � •alc� Environmental Health Permit/Services . Y` 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE a INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE �gPERMIT*NO. EH 13-241REV.1/A5) N ld c lO® 7-3-92- "L EH 14.26 7 i