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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 +3(_P9 P 0 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 Public Health Services. Job Address Bacon Is. & Little Mandeville Is. City Lot Size/Acreage New Island Farms & Owner's Namd'elta Wetlands Address As per attached map Phone Western Geophysical Co. P.O. Box 317, Bakersfield, Ca. 93302 (805)324 0405 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXX 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 ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f') Public �gV� sical XXDelta Depth of Grout Seal Type of Grout I 1 lrrigation30-5 O f . p ox. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State W rk one Well Destruction ❑ Well Diameter Sealing Material & Depth emenNn-fOnl e slurry or Depth Filler Material & Depth Bentonite w tremie pipe. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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, 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal all re red fictions. Complete drawing on reverse side. Signed Title: __ Permit Agent Date: 04-11-90 R. E. Buice FO DEPARTMENT USE ONLY qq Application Accepted by Date LD Area Pit or Grout Inspection�y Q�Date Final Inspection by Date 57 o' Additional Comments: S t c�I�y Applicant — Return all copies to: San Joaquin County Public Heal h �?✓ �� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT R�MITTED INFO RECEIVED BY PATE PERMIT'NO. + EH 13.24IREV.rin51 �� EH A629 -73 ' "�L2—