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APPLICATION SAN JUAQUIN COUNTY PUBLIC TD ICES ENVIRONMENTAL HEALTH 445 N SAN JOAQUIN, PHONE 20 404 P O BOX 2009, STOCKTONPERMIT E%PIRES I YEAR FRO(Complete in Tripl �Application is hereby made'to San Joaquin County for a permit to construct and/o application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Joaquin County Public Health Services. and Regulations of San Job Address 17807E Mi City Linden Lot Size/ a i� lnutS ij Owner's Name Jack La orio Address 5057 N. Alfalfa, ,Linder! Phone � -- - Box 64 Contraclo( Vlance Drillers Linden InQ ddress P. 0. License No. 377923 Phone 887-3554 I TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LENS 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 1-1- Dia. of Well Casing `S�a }&Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing`; Steel ' `.156 I( 1"I Public is Dther Specifications. ❑ Delta Depth of Grout Seal r-> 240 r i 9 SaC Sand & r 300 p Type of Grout I I irrigation A' r 14 pp ax. Depth I I Eastern Surface Seal Installed by CeflleTlt flappair Work Done 0 Type of Pump H.P. _ State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material i Depth ii Depth d Filler Material i Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDIT€ON i I DESTRUCTION I t lfJo septic system permitted if public sewer is ' . available within 200 feet.! Q 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 �I PKG. TREATMENT PIT. ❑ sal Distance to nearest: Well Foundation Qra�a MENMethod of DTI � 1)�7nY r [I LEACHING LINE ❑ No. b Length of lines Total len -hal, FILTER BED n Distance to nearest: Well Foundation El j PrOAR Line RT SEEPAGE PITS 11 DepthSize Nu �� M ii SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I I 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 Homeowner 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 11 employ anv person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ F. tion laws of California." p Persons subject to workman's compensa- The a licant mu all f It uj inspectiont. Complete drawing on reverse side. ,! signedTitle: Corporate Secretary 3/7/94 Date: 1 FOR DEPARTMENT USE ONLY it Application Accepted by Date Area f� Pit Grout spection by Date �' Final Inspection by Date Additional Comments:. ki Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 f © FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMITNO. INFO H . EH 13.26 iR j. i M 5) t ,l !�y/ f4-26 :;�, ! U / f�