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• APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED P O BOX 2009, STOCHTON, CA 95201 (209) `11111 01 1991 REMIT E_TiyIRES t YEAR PROM DATE ISSUED SAN.JOAQUIN CL "'ITY (Complete in Triplicate) PUBLIC HEALTHSi'.F:ic'ES ENVIRONMENTAL HEALIH DIVISION Application 1a hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is aide in compliance with Ban Joaquin County Ordinance No. 549 and 1e62 and the Rules and Regulations of San Joaquin County Public Health services. Job AddressLathrop Rd . City Lathrop Lot Site/Acreage Base Sharpe Army Depot p Lathrop , Calif, Phone 209-952-2425 owner's Name �ex _. ox Contractor Rindahl Drilling Address tC'oUr_ning, Calif. 960��ense No6015J5 Phone 916-824-0162 TYPE OF WELL/PUMP: NEW WELL LlC WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Hell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 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 El Industrial ❑ Open Bosom R Manteca Die. of Well Excavation Dia. of Well Casing n U Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC Specifications Q Public ❑ Other ❑ Delta Depth of Grout Seal Varies Type of GroulNeat Cemen ❑ Imoation Varikorox. Depth O Eastern Surface Seal Installed by Well Cap Repair Work Done ❑ Type of Pump H.P. Slate Work Done _ Well Destruction O Well Diameter sealing Material A Depth Depth Yiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION CI INo septic system permitted if public tower is available within 200 feet.) installation will "me: Residence _ Commercial_ Other Number of living units:'— Number of bedrooms Character of Soo 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. A 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 cenify 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 Sen Joaquin County Home owner or licensed agent's signature certifies the following: "I cenify that in the perlormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to wmkman't compensation laws of California." Contractor's hiring or subcontracting signature cenifies 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 applicant must call for all required in f etlont. Complete drawing on reverts side. Signed dQ��' Yrw.>� �p Title: Owner Date: 4-1-91 UFOR DEPARTMENT USE ONLY a/� Application Accepted by Data Area Pit or Grout Inspection by Date - 9 Final Inspection by Date Additional Comments: - Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RE EIVED BY DATE NFO Q EH 12.24 MIN.IIAs) __Y_ � 2 ^ 3 `4/ EH 11-M