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APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 448 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 'YEAR FROM DATE JASU (Complete in Triplicate) UP Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pubiic Health Services. Job Address 15616 Santos Rd. City Ripon Lot Size/Acreage 5 acres Owner's Name Valerie Peterson Address 15616 Santos Rd. , Ripon _ Phone 599-7240 Contractor_ Hennings Bros. Address 3525 Pelandale Mod. 95356ense No. 290813 phone 545-1185 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT XX DESTRUCTIONAX Out of Service Well C'1 ;t PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well O J DISTANCE TO NEAREST: SEPTIC TANK _ 9{]i r SEWER LINES DISPOSAL FLD. 10-0'f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 611 rX Domestic/Private IN Gravel Pack 0 Tracy Type of Casing_ HE Specifications I'I Public 1 1 the► Fl Delta Depth of Grout Seal i 0o t Type of Grout_ BEI] Qf13 e I I irrigation rC Approx. Depth I I Eastern Surface Seat Installed by-. driller . - Repair Work Done U Type of Pump H.P. State Work Done w Well Destruction )}( Well Diameter Sealing Material i Depth Bpnixon1to Depth Filler Material i Depth Bentonite TYPE OF SEPTIC WORK: 'NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feel.l Installation will serve:,I Residence Commercial— Other Number of living units: Number of bedrooms .. :� . Character of "i 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 Lina'! LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property LineR.1 . SEYEPAGE PITS I I t Depth Size Number, SUMPS Lt 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 Ihs Sen Joaquin County J. Home owner or licensed agent's signature candies the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follovAng: "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." , The applicant must call for all required inspections, Complete drawing on reverse side. Signed nin s. Bros. Title: Y Date: 3-23-93 FOR DEPARTMEN USE ONLY Application Accepted by - reg Pit o/8rot¢'Inspection by Dat -fid' -.Final Inspection pate �--J r f i AdditXom a � ^.ntr- ReIle t n all copies to: San Joaqufa County Public Health Services I l Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY D E PERMIT'N . EM 13-2411IEV.,in5) U)D EM 14.2e 99,T CY