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SAN .30AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 WELL No. 6 <br /> PMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate). <br /> Application 1s 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 /> nLot Size/Acreage <br /> Job Address <br /> 942 5. Stockton Avenue city. Rip�n- <br /> Simpson Paper CO._ Address 942 Phone[ - <br /> Owner's Name Rippon, CA 95366 9.16 <br /> Lawrence David A. znc, :dLa2001 Market . St. Rltt 5&q 5 1 `{7CS7Phone - <br /> Can tractor LaWreri e & AS OC Address <br /> nse No. <br /> TYPE OF WELL/PUMP: NEW WELL LJW LL REPLACEMENT Fl DESTRUCTION Cl Out of Service Well Ll <br /> OTHER ❑ Monitoring Well n <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ [ <br /> DISTANCE TO NEAREST: SEPTIC TANK? 100 ' SEWER LINES 7 1 OQ, 0'- DISPOSAL FLD.Z�IlOOP. LINE �flO ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> Dia. of Well Casing I <br /> #$Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Specifications. I <br /> C 1 Domestic!Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> I'1 Public <br /> ['1 Other n Delta Depth of Grout Seat Type of Grout <br /> 1 <br /> I I Irrigation Approx. Depth t I Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Sealing Material & Depth <br /> Well Destruction 0 Well Diameter <br /> Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INosepti systt m perm}e luted if public sewer isavailable <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity_ <br /> SEPTIC TANK ❑ Type/Mfg apy No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line <br />` LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or 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." Contractors hiring or subcontracting 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." <br /> The applicant st call for regyir inspections. Complete drawing on reverse side. <br /> Signori <br /> Title: president Date: 12/30 92 <br /> FOR DfAPARTM <br /> Application Accepted by <br /> Date � Ar <br /> Pit or Grout Inspection by <br /> Date Final Inspection b Date <br /> Additional Comments: <br /> } Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C1( RECEIVED BY GATE PERMIT'NO. <br /> INFO ! L <br /> [ fN-r3.zllRtv.vihsf <br /> EM tt-Ze <br /> { +1 <br /> I <br />