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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 PERMIT .EXPIR95 i YEAR I RPX PATE 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addrsea14.175 E . HWY 26 s _-- _-.City Linden_ -_- Lot Size/Acreage Owner's Na +inden Associated Gr -iAeX, s 14175 E. Hwy 26 Linden Phone ContractorDuryianCe Driller SgdAtiC- P-0-Box 64,Linden License No. 37797-3 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL IDWELL REPLACEMENT i'] DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION 9 SYSTEM REPAIR 0 OTHER ❑ Monitoring well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing � U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public i-1 Other ❑ Delta Depth of Grout Seaf Type of Grout CEIrrioation .,Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump ._turb H.P. 25 State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION F-I (No septic system permitted if public sewer is t 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. 0 ,4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest:_ Wsll_ Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS GI Distance to nearest: Well Foundstion Property Line DISPOSAL PONDS © yi 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: 1 certify that in this performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The alicant m t tail for 11 equ d inspections, Complete drawing on reverse side. Signed Tiue.Corp. Secretary _ Date .2/13/91 V EPARTMENT USE ONLY q Application Accepted by Date - 5— l� Area Pit or Grout Inspection by Date Final Inspection by �' Dates Additional Comments: Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 FEE INFO AMOUNT PUS AMOUNT REMITTED CASH REC IVSD BY DATE n PERMIT'NO. . EH 13.24 IREV. - EH 7620 ll