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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420r t <br /> P O BOX 2009, STOC%TON, , CA 95201 * <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance With Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 12105 W'RIPON R D. City RIPON Lot Size/Acreage <br /> owner', Name U N A W E R N E R Address 12105 W. RIPON RD. Phone 599-3606 <br /> Contractor HENNINGS BROS, DRILLAJdress -License No. 290813 _ Phone .545-1185 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IX DESTRUCTION X1 Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 t SEWER LINES 10.0 r DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> l� industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XADomestic/Private IN Gravel Pack Q Tracy Type of Casing_ PUC Specifications Af <br /> 1'1 Public f1t�O�thpr f 1 Delta Depth of Grout Seale Type of Grout_B.FT{}N T F <br /> I I Irrigation /7-eApprox. Depth 11 Eastern Surface Seal installed by H E N N I NGS B R O S:. DRILLING i <br /> Repair Work Done L3 Type of Pump H.P. StateWork 0 ' <br /> Well Destruction Wolf Diameter 6" Sealing Material & Depth BE IV T O IV I <br /> Depth 38 ' Filler Material & Depth v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to ■ depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> d <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl 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 ❑ <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 of licensed agent's iignature certifies the following: "l 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." Contractor's hiring or sub-contracting 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 must call for all required insAections. Complete drawing on reverse side. <br /> Signed tle: Data:A U G. 4 1992 <br /> R DEPA TMENT USE ONLY (� <br /> Application Accepted by Date l _ Area <br /> Pit o G,out nspsction by Date Final Inspection by Date <br /> Additional Comments: C�.d <br /> Applicant - Retu n all copies to: S n Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> �hFEE AMOUNT DUE AMOUNT REMITTED CASH IK RECEIVED BY DATE PERMI1'NO. <br /> • EH13.24(REV.I/ASS <br />