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APPLICATION FOR PERMIT l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 KI .TOB P O BOX 2009, STOCKTON, CA 95201 20-3694-01 PERMIT EXPIRES i XFM EMU DATE ISSUED sf/� Yjmplete in Triplicate) Application is hereby made San Joaquin Co. y for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. APN 9245-17-21 ! E of Jack Zone Rd,So of Clinton Road Ripon Lot Size/Acreage Job Address Crcy p Owner's Name 259 Forth Wilma Ave Address Ripon, CA 95366 Phone 599-2108 Contractor Spectrum/Kleinfelder Address 2825 E. Myrtle St. License No. 512268 Phone 948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT f7 DE3FRt1t��ff?!+f-i=l-9tet-'ef Be:„�crKei�"�'i PUMP INSTALLATION.0. _SYSTEM REPAIR ❑, OTHER EX Monstorsi+g.Mre]�-� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP:twE Wiest bori ngs FOUNDATION AGRICULTURE WELL —OTHER WELL` P1T3'tStIVP'S-15 to 251 eep INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ diamete El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -0iarefaAlel�fsaeing ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_.. -spe'Nicatimm 1'1 Public (-I Other171Delta Depth of Grout Seal fi I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Dona , Well Destruction ❑ Well Diameter" Sealing Material i,Depth I3 nth Filler Material i Depth I TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i JNo septic system permitted if public sewer is it available within 200 feet,I . Installation will serve: Residence_ Commercial r Other µ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 3 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest:. _ . Well Foundation Property Line S LEACHING LINE Cl No, 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: - Well Foundation Property Line SEEPAGE PITS I I Depth :' Sire Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i i 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, an i 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 dub-contracting signatur ' eandies 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 co..pen" tionlaws of Califor The applicantt ail or al required 'n t' mplete drawing on reverse side. gigue Title: Project Engineer Date: December 28, 199' F DZRTMI NT USE ONLY Application Accepted by Date 8 h _ Pit or Grout Inspection by Date Final Inspection - Date Additlonal Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE f AMOUNT f[EMtrrED C SH RECE VEO BY Y►TE PERMIT N0. INFO . EH 13-24 1r1Ew.f/n Ql t H 1•-26