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AiDpr.ZC,'tTTQN 10 oprobe Sampling Wells 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation$ of San Joaquin County Public Health Services. 500 East Louise Avenue City Lathro Lot Size/Acreage Job Address Libby OwenAddress s Ford, Co. 500 East Louise Ave. , Lathrop Phone 209-$58-6202 Owner's Name Vironex/Condor address Box 3448, Turlock, CA License No.705927 phone 209-668-923 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ OTHERS yfpnitoripg Well C]PUMP INSTALLATION C3 SYSTEM REPAIR C2leoproDe PROP. LINE !A DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES N/A DISPOSAL FLD. N A A FOUNDATIONAGRICULTURE WELL N A OTHER WELL N/A PITS/SUMPS !LA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation N/A Type of Casing Specifications [I Domestic/Private ❑ Gravel Pack ❑ Tracy N A Type of Grout I'l Public !�Other f1 Delta Depth of Grout Seal See Work Plan I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by H p State Wark Done Repair Work Done U Type of Pump 2n Sealing Material a Depth ;t:^ t (orknot '''`t>h Lk ntonite Well Destruction ❑ Well Diameter13 feet Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I [No septic hit system feet'led if public sewer is availableInstallation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE ❑ No. 8 Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation Number SEEPAGE PITS l I Depth Size Property Line SUMPS Ll Distance to nearest: Weil Foundation— 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, state taws, 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 the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." (See Work Plan dated 11/5/96) The applicant t call for all requir inspections. Complete drawing on reverse side. Signed X Tide: 1!0—aging Geolo ist Date: N 25 1996. X. uaviu riuftuu FOR DEPARTMENT USE ONLY � ule� Date L `d l Area Application Accepted by Pit or Grout Inspection by �� Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin Countp Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boz 2009, Stka, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED By DATE PERMIT NO. INFO } �j-� f� • EN 13.24(REV.t/n51 Q�� .,a.. w 42•f�Z�" V t� EH 11.26