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. APPLICATION FOR PERMIT ! - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 KI JOB P 0 BOX 2009, STOCKTON, CA 95201 20--3694=01 PERMIT EXPIRES 1 YEAR FROM DATE ISSUrD 7 �! ( om 1 in Triplicate) /Application is hereby made.to San J iUF2i4U-3:Yy forrmit to construct and/or install the vork herein described. This application is made in compliance.xit Sordinance No. 549 and 1862 and the Rules and Regulations of San 1 Joaquin County Public Health services. 17 and 243-30-02 I Job Address Jack Tone Road ,& Hwy 99 City Ripon hot Size/Acreage -City of Ripon 259'North Wilma Ave,Ripon, CA Phone 599-2108 _ Owner's Name Address Contractor Spectrum/Kleinfelder Address2825 E. Myrtle St. License No. 512268 Phone 948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M Out-o:P-9e»1ee-_Ve1r_e .� PUMP INSTALLATION ❑ a - - W SYSTEM REPAIR ❑ OTHER XX DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. i'3>fQP.-L-NE 3 test bori gs FOUNDATION AGRICULTURE WELL OTHER WELL '_Pt•T_S*90l FPS 15 to 50 r de p a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- diametewilr 0 Industrial O Open Bottom ❑ Manteca Dia. of Wali Excavation Dia.-of well-Ca;;ing --r tt�o n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Sspeeit+oatiena h 1 p g F1Delta -Depth of Grout Seal aTypFgf�ut-hack i��- II'] Public rl'Olherhack backfill I Irrigation Approx..Depth I I Eastern Surface Soul Installed by holes if groundwater_ Repair Work Done 0 Type of Pump H.P. State Work Done encountered. Well Destruction ❑ Weft Diameter Sealing Material i Depth Depth Tiller Material i 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'-___ Other # Number of IhAng units: Number of bedrooms- F. Character of soft to a depth of 3 feet:l Water table depth i SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 6 Length of lines " Total length/size FILTER BED 0 Distance to nearest:. -Well Foundation Property Line SEEPAGE PITS I I Depth f Size m Number SUMPS Ll Distance to nearest:. -Well -- Foundation Property Line r 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, slate laws, and rules and regulations of the San Joaquin County ` 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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- tion larva of Califor The applicant at r all uir in a drawing an reverse side. I Signed Title: Project Engineer Date: December 28, 1992 i i � FO DE FITMENT USEONLY r� Application Accepted by Date �'" A Plt 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 aaY� 445 N San Joaquin, P 0 Box 2005, Stkn, CA 95201 ! a4- FEE AMOUNT DUE AM UNT REMITTED CC K RE EIVED BY7, OA E PERMIT NO. 1 "d EN 13.24IRV,FiN615 � ?/�//yd14.76 1f !/✓ F, .