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APPLICATION FOR PERMIT a� <br /> { SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES # <br /> ENVIRONMENTAL HEALTH DfVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 PAYPM ` <br /> - P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> PENIT EXPIRES 1 Y FRObd t E P 17 1932 <br /> -- I , <br /> (Complete in Triplicate) AN JOAQUIN COUNTY <br /> PUBS iC HEALTH H SEiRVICt'ECS <br /> Application Is hereby made,to Sand <br /> oaquiri County for a permit to construct and/or inata'1WV}.RQ( � �I� ,hde'Bc1� Ced�� hi5 <br /> l application se made in com+pllence vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> - Joaquin County Public Health Services. <br /> eO-L(' v ,4=u G. ¢�. — t (b 2--030--o f <br /> : Job Address Rough_ & Ready Island NCS Stockt <br /> City Stockton Lot Size/Acreage 1400 acres <br /> Owner's Name U.S. Navy Address Roou h & Ready_C Phone( ()91 944-04 <br /> 2120 Blumenfeld Dr. , California I� <br /> Contractor Tonto Drilling SVCS Address Sacramento, CA 95815 License NOC _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [J OESTRUCTION ❑ Dut of Service <br /> Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHE sorSting Well L]DISTANCE TO NEAREST: SEPTIC TANK > 50' SEWER LINES 50 r DISPOSAL FLD)50' PROP.OP. LINF>LO01 <br /> FOUNDATION 150 r AGRICULTURE WELL?100 r OTHER WELLI-% r - PITS/SUMPSi,-raL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1-] Endustnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tet-]Domestic/Private 10 Gravel Pack 0 Tracy Type of Casing - Specifications ;I <br /> I'I Ikrblic n Other Delta Depth of Grout Seal 50' Type of Grou Neat Cement _I <br /> I I Irrigation _Approx.r Depth i I Eastern Surface SenE Installed by <br /> Repair Work Done 0 Typs of Pump H.P. Stats Work Done_ L <br /> Wall'Destruction C3-I Wo Diameter _ , Sett Ing hfatdrial i Depth <br /> Death Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo sepnc system permitted it public rawer is <br /> available within 200 feet.l <br /> Installation will.servo: Residence! Comnnarcial� Other „�:.` _ <br /> Number of living units: Number of bedrooms , <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C) Typeliiilfg Capacity `No. Compartments <br /> PKG. TREATMENT PLT. ❑ '' <br /> Method of Disposal <br /> Distance to nearest: Well Foundation property Line <br /> LEACHING LINE ❑ No. ✓i Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation_ Property Line <br /> SEEPAGE PITS 11 Depth ! Size Number <br />? SUMPS LI Distance to nearest: Well Foundation <br />+ Property Una <br /> DISPOSAL PONDS. ❑ <br /> I.hereby cantly that I have prepared this appacatlon and that the work will be done in accaroance with San Joaquin county ordinances,state laws, and <br /> ' rules ono regWaliarn of the San Joaquin County 777 <br /> Home owner or licensed agent's signature candies the following: -I certify that in the performance of the work for which this permit is'issued, I shall not ' <br /> employ any person in such manner as to becorsia subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fonowing: "I candy that in the Partormance of the work for which this permit is issued,I shall employ Persona subject to work <br /> tion laws of California." h men's compensa- <br /> The applicant must cal f all required ins . Camplate drawing on reverse side. <br /> Sr!t^0a �' Title: Cg/0,111L;1 , e� lel? n Date: <br /> G✓e� 144 [1 e e FOR DEPARTMENT USE ONLY �7 <br /> Application Accepted by Date �� r " Area <br />- Pit or tirout Inspection f Date Final Inspection by Data <br /> Additional Comments: fly <br /> Applicamt - Return all copies to: IS., uin C ty l9blic Health - <br /> Services, Eavironmeazal Health Permit/Services <br /> 1541 E. Hazelton Ave.. P D Box 2009, Stockton, CA 95201 k <br /> INFO AMOUNT DUE . AMOUNT REMITTED CASH <br /> gn�Q RECEIVED By DATE PEAMITNO. <br /> . EH 13.24I14EV. Pam <br />