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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> "\ PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 1 <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and. 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 1-6d42 E. Baker Lane City Linden Lot Size/Acreage <br /> owner's Nam.C` & A Lagomarsino Address 16042 E. Baker, Linden Phone <br /> Contractgurviance Drilles,Ilm3ress, P.O. Box 64I[Linden�JCQe No. 377923 Phone - <br /> TYPE OF WELL/PUMP: NEW WELL)t7 WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION)L SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 1�9 Open Bottom ❑ Manteca Dia: df Well Excavation Dia. of Well Casing <br /> L1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing__ ! Specifications R8 <br /> I"1 Public, 17 Otter n Delta Depth of.Grout Seal grin r a" Type of Grout cement <br /> t�Z Irrigation 5 6 Approx. Depth I I Eastern Surface Seal Installed by G <br /> Repair Work Done U Type of PumpT trrh_ H.P. 40. ` ' State Work Done <br /> Well Destruction . ❑ _.Well Diameter Sealing Material ` Depth <br /> -- — Depth Filler Material-.6'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONA I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence= -Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well_ Foundation Property Line <br /> LEACHING LINE ❑ -No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth _Size___ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "ecertify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's Compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The p4cant m t call,f req re inspections. Complete drawing on reverse side. <br /> Signed Title: ( r)—rp Secretary Date: 917 fA? <br /> FOR DEPARTMENT USE ONLY /� <br /> Application Accepted by , "1-3::12- <br /> A . +�,..Q_- Date t^3:: 1q 2--- Area D C <br /> Pit or Grout spection by i / Date r /o Final Insperttion by Date <br /> Additional Comments: � faA" k4-�,Gt.c � 12:�,jy 3,2 <br /> U7/-/, � �✓�> ���"'�� <br /> Applicknt - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Servicesv <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 952, <br /> EE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 1344 IREV.1/.5) �y G t5 <br />