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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in 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 Regulations of San Joaquin County Public Health Services. t r,r{'A-) t• n -troy T-"— T.i nrlon r.,.. sr—/e...,... Job Address AMOUNT DUE & A Lagomarsino Address 16042 E. Baker, Linden Phone owner's Nam eC' DATE Contfactgurviance Drilles , IWress P.O. Box 64 , Linden Lice No. 3-713-23— Phone - TYPE OF WELL/PUMP: NEW WELL> 1 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALATION)U SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 19r Dia. of Well Casing 12 314' Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ` Specifications AA I•I Public fl Otter f1 Delta Depth of Grout Seal 2 IS 0r a" Type of Grout_ CaMcz It a Irrigation 5e{ 2.a Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of PumpT.11rh H.P. 40 State Work Done _ Well Destruction - i_ ❑ ,.Well Diameter Sealing Material i Depth `- Depth Filler Material-'& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION'l I INo septic system permitted if public sewer is available within 200 feeLl 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 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 I I Depth Size 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." Theplicant m t call f regyire inspections. Complete drawing on reverse side. Application Accepted by s `^� Pit or Grout spection by / Additional Comments: ' F Applicant - Return all copies to EH 13-24 IREV, I/ a 5 EH 14-26 n FOR DEPARTMENT USE ONLY Date - ` }Z Area C) Date q !o ?_ Final Inspe;tion by Date X) // /1 Z /J,:„af'v /Jw !/Hi lJ�#1 _ fL.% 3X) / . G/Yr_._0 ��q/_/. �,.�,aA z m� San Joaquin County Public Health Services �cK tai. y, Environmental Health Permit/Services Mn�v� ✓t .�/�' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 / FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE PERMIT NO. INFO CASH 4►" J� N