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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL;HEALIH DIVISION <br /> 1601 E. HAZELTON AVE:, .PR0NE: (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RES I YEAR FR M DAT ED <br /> (Complete in Triplicate) <br /> o <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 19277 E. Hwy. 1- 4 City <br /> Ripon Lot Size/Acreage <br /> Job Address l�2 acre <br /> Fred & Kathy D&AcheliS Address 19277 E. Hwy. 120 Phone <br /> Owner's Name �� � <br /> Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L) <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PR08LEM AREA. CONSTRUCTION-SPECIFICATIONS <br /> CI Industrial ❑ Open [3ottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private 0 Gravel Pack ❑ Tracy Type.of Casing Specifications <br /> I"1 Public C] Other n Delta t ;Depth of Grout Seal Type of Grout <br /> I I lrriga[ion �,Approx,+Depth I I Eastern , . Surface Seal Installed by _ <br /> Repair Work Done 0- _Type of Pump H.PState Work Done <br /> Well Destruction 0- Well Diameter <br /> Sealing Material & Depth <br /> Depth qFiller Material & Depth <br /> YPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION DESTRUCTION IJ iNo septic systethin m rented if public sewer is <br /> availabInstallation will serve:. Residence X i Commercial Other <br /> Number of living units: I _ Number of bedrooms�� s <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. ❑ ,e Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 31 <br /> t <br /> LEACHING LINE '[X No. & Length of lines 1 60' Total length/size 60 <br /> FILTER BEDCl Distance to nearest: Well 100 Foundation 60 Property Line <br /> SEEPAGE PITS 11 Depth 10' _Size 24" X 10' Number 1 t <br /> j SUMPS 'LI Distance to nearest: Welt 100' _ Foundation 60' Property Line <br /> DISPOSAL PONDS ❑ <br /> ereby 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 /> 4 rules and regulations of the San Joaquin County <br /> Home owner of 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 <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." r <br /> f r .. <br /> The applicant ust c or II required.in ctions. Complete drawing on reverse side. <br /> —91 F # <br /> KSSIT <br /> gned M Title; ` � 1 - -- — Date: <br /> f 0R USE ONLY t <br /> [ Application Accepted by Date as <br /> tp[1{4y Pit or Grout Inspection by Date Final'Inspection by Dataf��-'7 <br /> It1 <br /> Additional Comments: <br /> Applicant - Return ell copies to: San Joaquin County Public Health s <br /> t Services, Environmental Health Permit/Services <br /> 16011E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> IFEE PNFO NT DUE r AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'N0. <br /> . Eli 11,2 1HEV.-hin51 �� I r� � ( ZI I 1 <br /> EH 14.26 <br />