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APPLICATION FOR PERS!I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 w P O 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 rade in compliance with Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 930 W. MAIN City RIPON Lot Si../Acreage , deF c` O S I`f A L Owner's Name BETHANY NOME CONV . Address 930 W. MAIN RIPON Phone 599-4221 contractKENNINGS BROS. DRILL. Address 3525 PELANDALE AVE.MOD,95356 or License No. 2 9 O 81 3 Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 10 But of Service Kell 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell C7 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 L) Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public El Other Cl Delta Depth of Grout Seal Type of Grout I 1 Irrigation _Approx. Depth I 1 Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. Mata Work Done T Well Destruction IN Well Diameter 1 0 11 Sealing Material & Depth e n t o n 1 t e- 'b t CAg Depth 15Q , Filler Material i Depth Pea Gravel - up to-120" TYPE Of SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ( I DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 10 Number of living units: _,_,_. Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Cspacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation Property Line 37 SEEPAGE PITS l I Depth Size Number SUMPS LI 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, stele 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 laves of California." The applicant must call for all required inspections. Complete drawiVg on reverse side. Signed F - tie Date: 3-1 -93 R DEPARTME T USE ONLY Application Accepted by L C% haw� _ Date _ ea Pit or Grout Inspection by Data Final Inspection b Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 CK J INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED OY DATE PERMITNO. r EH 13.2 (REV.1 r 5) 0 iC7 f7 0 e,p� 3/ EH 14-26 C7 l (�