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APPLICATION FOR PERMIT 1L� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r V� ENVIRONMENTAL HEALTH-DIVISION I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, .STOCKTON, CA. 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete is 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 ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 475 W. BLEWETT ROAD __ City TRACY Lot size/Acreage Owner's Name C&A NAVARRA RANCH Address 475 W. BLEWETT ROAD, TRACY_ Phone 836-0005 Contractor NOACK PUMP CO. Address 4500 E. FREMONT, STKN License No. 504513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR 0 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 s L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout XI lrri{tatlon —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpTITIIRRTNFTNF H.P. ,100 '� State Work Done— INSTALL TIIRBINE PUMP Well Destruction ❑ Well Diameter Sealing Material & Depth 141 f,ICId lJL LL. Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I 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 ❑-'Typ0/Mfg Capacity No. Compartments �} V PKG. TREATMENT PLT. 0 Method of Disposal � / Distance to nearest: Well Foundation Property Line .LEACHING LINE D No. & Length of lines ► Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number =, SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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," Contractors 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." _ - - . - _.ti The applic nt ust li for II et}uired�i p ti mplete drawing on reverse side. r Signed X D O [ title: RETAIL SALES - ' "oat: - G-C?_/ w FOR DEPARTMENT USE ONLY Application Accepted by Rate - Area + Pit or Grout Inspection by Date Final Inspection by Date f Ey' Additional Comments: F Applicant -.Return all copies to: xSan Joaquin County Public Health Services, Environmental Health,Fertnit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r IN AMOUNT /DUE AMOUNT REM% ITTED iF ASH RECEIVED 8Y DATE PERMIT'NO. EH 14-2624 3.24 IREV.ri x Si / 1 �� `A-D-(U