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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 (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct 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 Services. Job Address NE Ripkin Property APN 1.14--202-02 City Stockton Lot Size/Acreage Owner's Name GRUPE DEVELOPMENT Address 2291 W. March Lane Phone 473-6155 Contractor CLARK WELL, INC Address 2024 E Charter Way License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (71 DESTRUCTION g Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well it 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 C3Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'I Public Cl Other n Delia Depth of Grout Seal Type of Grout 11 Irrigation Approx. Depth I I Eastern Suriaes Seul Installed by Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material S Depth Depth Filler Material & Depth — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR,ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial ._. Othei n Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth CCC 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 O Distance to nearest: Well Foundation Property Line �i SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundaticn 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 the San Joaquin County Home owns r 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 employ an son in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th I fol wing: 'I certif tha6in 6ntio rm nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ifornia.',The applica t t call all r qun Complete drawing on reverse side. Signed X Title: Sec—Tres Date: 4 Dec 91 FOR DEPARTMENT USE ONLY Application Accepted by Date —�/ Area 36 Pit or Grout Inspection by Datey 91 Final Inspection by Date Additional Comments: n Applicant - Return all copies to: San Joaquin County Public Health Services O ;�O Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO //'� CASH / 9 • EH 13-24(REV.�insr alb �v 6 / ��/ EH 74.20 VVV!!! l/ CCC///