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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County;,Pti}al,iRLE I]th ,S�exacicgs. Job Address INOORTJH WEST END OF BACON( ISLAND City STOCKTON Lot Size/Acreage Owner's Name RANCHO DEL RIO Address P.O. BOX 343, STOCKTON, CA 952phone 464-7979 Contractor NOACK PUMP COMPANY Address4500 E. FREMONT, STOCKTOItlicense No. 504513 phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER ❑ 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 n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X-XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump SUBMERSIBLEM.P. 1 HP State Work Done_INSTALL 1 HP SUB .PUMP Well Destruction ❑ Well Diameter Sealing Material & Depth IN NEW WELL Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. CompartmentsV`' PKG. TREATMENT PLT. O Method of Disposal C13 Distance to nearest: Well Foundation Property Line Z LEACHING LINE_ . ❑ No. & Length of linesTotal length/size FILTER BED K . O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, anck" 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 laws of California" The applicant must call for all r�OR spe4' �. o ete drawing on reverse side. r C Signed X_ \ Title: RETAIL SALES Date: F DEPARTMENT USE ORLY Application Accepted by Date - I�� Area Pit or Grout Inspection by Date Final Inspection b�-1l/ �� Date Z111-01/1- Additional 01Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/n s) �_r `� (�0 _ EH 1/.2a r l l V Vit+