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NOON � AaPL IC.1TtnK 10 GGeeoprobe Sampling Wells AN JOA IIIN COUNTY PUBLIC HEALTH SER110ES S Q ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT =IRES_ I YEAR FROM 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 is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. 500 East Louise Avenue City Lathrop _ Lot Size/Acreage Job Address Owner's Name Libby Owens Ford, Co. Address 500 East Louise Ave. , Lathrop Phone 209-858-6202 Contractor Vironex/Condor Address Box 3448, Turlock, CA License No.705927 Phone 209-668-923 TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ out of Service Well ❑ OTHER 1 nitorigg Well [3PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ heoproDe DISTANCE TO NEAREST: SEPTIC TANKN/A SEWER LINES NSA DISPOSAL FLD. N/A— PROP. LINE L AU FOUNDATION N A AGRICULTURE WELL N/A OTHER WELL NSA PITS/SUMPS _NZA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 21v C] Industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation N/A Dia. f Well Casing �l pomesticlPrivase ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f�Other 0 Delta Depth of Grout Seal N A Type of Grout I'l Public See Work Plan I I irritation —Approx. Depth t I Eastern Surface Seat Installed by Repair Work Done L7 Type of Pump H.P. State Work Done 2rr sealing Material i Depth &at cement rb-4Z�entonite Welt Destruction 0 Well Diameter Depth 13 feet Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNoseptic system m permitted it public sewer is avaInstallation will serve: Residence— Commercial — Other Number of living units: Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK. C3Type/Mtg Capacity Na. 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L:i Distance to nearest: Well 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 county ordinances, stats laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature canifies 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 subcontracting 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 t all for all requir inspections. Compiate drawing on reverse side. (See Work Plan dated 11/5/96) Signed X Title: Managing Geologist Date: Nov 25. 1 996. Vld melide FOR DEPARTMENT USE ONLY Application Accepted by Date Area pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 fEE AMOU T DUE AMOUNT R MED CASH RECEIVED BY DATE PERMIT'No. INFO • EN 17.24 IrtEV,r/w37 eu �� tu7+t "ii