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1 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL H ICES 4408 ENVIRONMENTAL HEALTH DIV -- 445 N SAN JOAQUIN, PHONE (209 4 0 P O BOX 2009, STOC%TON, CA PERMIT EXPIRES 1 YEAR FROM DA AMV#ED (Complete in Triplicat Application is hereby alede,to San Joaquin County for a permit to construct and/or install the work herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and),862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1945 E. LATHROP RD. coy--�ktMP Lot size/Anreage Owner's Name WESTERN STONE PRODUQ,15,ss P .O. BOX 3171 ,MODESTO Phone 858-2451 Contractor HENNINGS BROS. DRILL-Address 3525 PEL . License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 2 6 1 SEWER LINES 260 I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �ir CI Industrial 6-0- Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r1 fl Domestic/Private IN Gravel Pack C3 Tracy Type of Casing_ PVC Specifications 160SCh I'1 Public ,9 I1 Other Fl Delta Depth of Grout Seal , -air Type of Grout R F N T O N T T F I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by H E N N I N GS B R O S. DRILLING Co. .,, Repair Work Done U Type of Pump H.P. _— State Work Done_ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Piller Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 11 (No septic system permitted if public sewer is �. available within 200 feet.] Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms P Character of soN to a depth of 3 feet: I ter table depth SEPTIC TANK ❑ Type/Mfg Capac Corr,pertmenp PKG. TREATMENT PLT. ❑ IN ethod of Disposal Distance to nearest: Well F y LineEftim LEACHING LINE ❑ No. b Length of lines G ` FILTER BED ❑ Distance to nearest: Well Foundation 9�e Q SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion In"of California." The applicant must call for all required inspections. Complete drawingon reverse side. Signed X\\_ DXVvv1A^� brine Date: MAY 5 , 1994 FOR DEPA =ENT USE ONLY Application Accepted by Date Area Pit or ou nspection by Date, V, Final Inspection by Data �. I 99 - Additional commenu: Q . � Applicant - ReWX tu all co Ses to: a oaqu Cou lubll�cRHealth 3ervlces o D / Environmental Health Permit/Services AL IIJW911� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FE AMOUNT DUE AMOUNT REMITTED _C_ --. RECEIVED BY DATE PERMIT NO, 1'TJ , tQ is IN CASH . EN to-N(REV.veal 7 �,r-1'1 EN U at