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LA__A 1Vll SAN JOAQUIN COUNTY PUBLIC HEALTH S ENVIRONMENTAL HEALTH DIVISIC ND 7r44 445 N SAN JOAQUIN,PHONE(209)469- 4 O BOX 388,STOCKTON,CA 95201-0 8�-n c PERMIT EXPIRES 1 YEAR FROM DA E ISS ED (Complete in Triplicat ) k O V 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 wrt an Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1981 8 South Lyorth Ripon Road City RiZnon Lot Size/acreage OQ 3178 Owner's Name Yvonne Cook Address As Above Phone 599- Modesto, CA Contractor Arrowhead Con. Address1 581 Cummins DR - #14 3 License No. Phone 574-0851 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION D out of Service Hell U PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER O Monitoring Well 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 Cl Industnal O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ [I Domestic/Private O Gravel Pack L-1 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout G i I itrr0auon __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Dona _ C Well Destruction O Well Diameter Sealing Material L Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is l available within 200 fest.) Installation will serve: Residence _ Commercial — Other �. / !J �-' A/I J _��— f`� Number of living units: Number of bedroomst' / Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE O No. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Founaatron Property Line SEEPAGE PITS 11 Depth Size Number t SUMPS LI Distance to nearest: Welt Foundation Property Lina DISPOSAL PONDS O 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 of tub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicantcall for at required inspections. Complete drawing on reverse side. 7),50-� Signed X_ Title: �IC�S/DE/�T Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area �It Pit or Grout Inspection by Date Final Inspection by Date 4 , Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 P C, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. c INFO CASH EH 13741NEv.tir.sl E H 14 20 VVV — r—