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APPLICATION (A 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 compliance with San Joaquin County Ordinance No. 549 and.1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6042 E. Baker Lane C;tY Linden Lot size/acreage Owners NameC` & A Lagomarsino Address 16042 E. Baker, Linden - Phone Contractp,urviance Drilles,Interess P.O. Box 64,Lindell LJcClae No. 377923 Phone 8 8 7- TYPE OF WELL/PUMP: NEW WELD) WELL REPLACEMENT [I DESTRUCTION D Out of Service Nell ❑ PUMP INSTALLATION] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D 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 F Industrial ) Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private D Gravel Pack ❑ Tracy Type of Casing r Specifications-- .1- R I') Public I Otf�er fl Delta Depth'of:Grout Seal 2 ' a'S Type of Grout_ t-r lWr.nf- 1,1,t Irrigation 572 z Approx. Depth I I Eastern Surface Seal Installed by G Repair Work Done E Type of PumpTltrh H.P. 40. State Work Done Well Destruction ) D Well Diameter_ Sealing Material 4 Depth N Depth Filler Material 6 Depth F TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ) REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) •��, - 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 Y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 3 LEACHING LINE 0 "No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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: "Pcertify 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 iz issued, I shall employ persons subject to workman's compensa- tion laws of California." The plicant m t call f req re inspections. Complete drawing on reverse side. Signed CL Title: ('nrP Date: 9 /2/-92 FOR DEPARTMENT USE ONLY 4 Application Accepted by `� � str,. 1 C3. Date, ��.� Area p � p / A Date //fPit or sPection by + Date a. Final lnsec�tion bG Additional Comments: -r ( G% Gtc ,ter .�il'L` 3 U t✓ll> o �� ec% /!�, Applicant - Return all copies to: San Joaquin County Public Health Services 144 Environmental Health Permit/Services. 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 CK FEE EH 13-24 IREV.�i H S� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY G DATE PERMIT NO. 77 • EH 11.24 �N c X17 lf7 o I ! � �"t` (� \ j