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APPLICATION FOR PERMI- <br /> SAze JOAQUIN COUNTY PUBLIC HEALTH—SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 /> Job Address 18800 S. Murphy Rd. city Ripon Lot Size/Acreage <br /> Owner's Name Ripon Fire Dept. Address 142 S. Stockton Ave. Phone 599-4209 <br /> Contractor NRS Home_ ADCs fano(Address 215 Main. Ripon. CA License No. 345755 Phone 599-3456 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Cl OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing <br /> 60 Domsstic/Privets ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other Ll Deltas Deblh of Grout Seal Type of Grout <br /> I I hrigetion --Approx. Depth I I Eastetn Surface Seal Installed by / <br /> Repair Work Done L1 Type of Pump Sub H,P. Shp State Work Done _ 1 <br /> Wait Destruction ❑ Well Diameter Reeling Material L Depth VVV <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permitted if public sewer is <br /> available within 200 feeIA <br /> Installation will terve: Residence _ Commercial _ Other <br /> Number of living unite: _ Number of bedrooms / 1 <br /> Character of toll to a depth of 3 feet: Water table depth �J <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. g Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation PProperty Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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, <br /> rules and regulations of the Son 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 rnanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <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 compenaa <br /> tion laws of California." <br /> The ap icant ustd'ccall r all r I1as\. Complete drawing on reverse side. <br /> Signed X\-Ml .,SZ, ;9/h ctIo11a title: Sales Manager Date: October 15, 19 <br /> �Cs?v/ DEPARTMENT USE ONLY <br /> Application Accepted by - Date / Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> FH4 /-S,;,NIIpp C) 6o "o tui I —M(I- I lIl --acs <br />