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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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r,,,, eri1ro« 16042 E. Baker Lane r;,,, Linden Lot Size/Acreage Owner's Name C & A Lagc narsino Address1 6042 _E Baker, Linden Phone 209-887-3554 ContractorITVianCe DrilleS,InC.Add,,ss P.O.Box 64,Linden License No.377923 Phone 209-887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION JkOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/ Private 0.G`avel Pack ❑ Tracy Type of Casing_ Specifications : I'i Pftblic- � � -"1 1 -Other -i -- P -Delta— - - ---Depth of -Grout -Seal-- ---Type.of.Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by r GdmQnt Repair Work Done L3 Type of Pump r H. P. State Work,Donl_ I ` �a 1 r Well Destruction l Well Diameter ��GL Sealing Materiel i Depth ' - 9s�Ck Sand & dement / e. Depth �/b/ Filler Material i Depth Sand'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other f Number of living units: Number of bedrooms f� - Character of soil to a depth of 3 feet: i Water table depth } SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ f w Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 1-1 Distance to'neirest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size i Number SUMPS LI 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, 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, 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: "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 applica must call f all u spections. Complete drawing on reverse side. Signe d X(1 jjj// jTitle: President Date: 2/16/93 FOR DEPARTMENT USE ONLY // Application Accepted by Date 6 �� Area �`/ Pit or Grout Inspection by ' Date Final Inspection by Date p Additional Comments: /� 5 3 (r o z t Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 . EH 13-21 (REV. I/ M 5 EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DA E PERMITNO. 00 r N/