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APPLICATION SAN JOAQUIN COUNTY PUBLI ENVIRONMENTAL HEALTH M$ ION I 445 N SAN JOAQUIN, PHONE P 0 BOX 2009, STOCKY AJ[Y# 95201 L 9�5 PERMIT EXPIRES 1 YEAR E ISSUED (Complete in Tri Application Is hereby made.to San Joaquin County for a permit to cons �T4n#o �oaetl ed. This application is made In compliance with San Joaquin County Ordinance s of San Joaquin County Public Health Services. _Q Job Address .1172IV. Z&7 tie( City 1_GL4�Lt� Lot Size/Acreage owner's Name Karl Grupe Address 14404 E. Hwy 26, Linden Phone 931-3581 Contracto rviance Drillers,InCAddress P•o•Box 64 Linden License No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION Cl SYSTEM REPAIR X OTHER 2 �Ov6L&°G �Monitring Well C7 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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.l Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing___ Specifications ('I Public (-I Other I1 Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. _._ State Work Done-double check installed Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE L� No. & Length of lines Total length/sizer."� a O - , FILTER BED ❑ Distance to nearest: Well Founaation Property L A. r SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Li 0 4< �= DISPOSAL PONDS El <,,.'Yr•u"i< I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count}/ordiiv 'ccs, 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 peat t)s 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." Thea scan ust call for r ed inspections. Complete drawing on reverse side. Signe Title: Corporate Secretary Date: 2/28/94 (� FOR DEPARTMENT USE ONLY Application Accepted by \, _ Date At Area Tq Pit or Grout Inspection by Date Final Inspection by y Data a �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. OINFO /� EH 132 IRE river G.1�j /�—�l `a EH 14.26 !! ! v