Laserfiche WebLink
APPLICATION <br /> SAN JGWIN COUNTY PUBLIC HEALTH S#ICES 80-5408-93 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 well abandonment <br /> P 0 BOX 2009, STOC%TON, CA 95201 Mid 93-2 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application to made in compliance with San Joaquin County Ordlnance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> 500 E. Louise Avenue city Lathrop Lot Slze/Acreage 160 acres <br /> Owner's Name Libby Owen Ford Co Address 500 E. Louise Ave , Lathroi I,pne209/858-5151 <br /> Contractor Spectrum Exp , InCAddress 2825 E. Myrtle License No. 512268 Phan�09/465-87 2 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION Z Out of Service Nell C <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 750 r SEWER LINES 7 50 DISPOSAL FLD� 50 PROP. LINE�SO 1 <br /> FOUNDATION 2�_� AGRICULTURE WELL7_�L� OTHER WELL 5�_ PITS/SUMPS ;L100 r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4`I <br /> C Industrial C Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C Domestic/Private XGravel Pack C Tracy Type of Casing S,AL, Specifications <br /> 1'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout CPM <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by ��7 47i,m <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction Well Diameter yll Sealing Material i Depth <br /> Depth 2 y`r Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION ! 1 REPAIR/ADDITION i DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of wil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> Distance to nearest: Well Foundation Property Lim <br /> LEACHING LINE C No. & Length of lines Total length/size <br /> FILTER BED C Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lim <br /> DISPOSAL PONDS C <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner w licensed agent's signature oartifles the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become wbinct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies ing: ""I certify that in the performance of the work for which this permit is issued. I shall employ parsons subject to workman's compensa- <br /> tion ws of Calif rnia. <br /> Tha"applwan,mut call for ajj7,ed ins Cti triplets drawing on reverse side. <br /> Signed <br /> i Title: Manager Date: 12-3-93 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data 2 Area <br /> Pit or Grout Inspection by Date Final Inspection by map DataLL1 <br /> Additional Commence: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services �(�6�J <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 !r- <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH R OEIVED By GATE PERMIT'NO. <br /> INFO ASH <br /> . ER 1a.24 IREV.fixer ,vv U!`i •� 'fl/ l �� �/� oo ✓�f <br /> EN 14-2111 <br />