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., APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' pmplete in Triplicate) Application is hereby made.to San Joaquin County or a permit to c n rust 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 Servi e ��/KtfLS south side Job Address City, Ripon Lot Size/Acreage SS acres_ Owner'sName Minard Roorda,j Address 25960 S. hl115t111 Rd. , Ripon Phone - HennAn s Bros. .. Contractor Address 3525 Pelandale Modesto License No. 290513 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL (X WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLS OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR_ EA CONSTRUCTION SPECIFICATIONS 111 Industrial ❑ Open Bottom t El Manteca Dia. of Well Excavation pia. of Well Casing II 1 Do estic/Private M Gravel Pack ❑ Tracy Type of Casing_ RVQ Specifications I ,Pu is (-I Other fl Delta Depth of Grout Seal t Type of Graut Be I` Ix fr gation _ ApproJ Depth I ) Eastern Surface Seal Installed by driller pair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ -Well Diame4r Sealing Material i Depth Depth. Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION [ I REPAIRIADDITION I 1 DESTRUCTION I ! INo 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl 'No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well foundation Property Line SEEPAGE PITS 11 Depth -„ Size `Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 signatuie certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as tabecome subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ arsons subject to workman's compensa- tion I P YP 1f1 . awe of California." The applicant must call for all required inspections..Complete drawing a averse side. Signed X Hennings Bros. By Title: Date: 7--29-92 FOR DEPA EON ,. Application Accepted by .Date Z Area Pit or Grout inspection by Date Final Inspection by �� Date 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DYE PERM17'NO. . fH13-1�tREv.ii�a� WN n '.", % � '/ I � EH 71-ZE �;