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A. APPLICATION FOR PERUIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (2051)468-3420 P 0 a�� 'BOX 2009, STOCKTON, CA 95201 � � 2 SANJ n,,. EXPIRES 1 YEAR FROM DA PUG L r�'`fN �r`NT (Complete in Triplicate) V�� N.IE�rT�� S ,wt/l� Application is hereby made to ps Sea J M`�` ��LI;Nr oaquin County for a permit to construct and/or install the work herein described. Ttss application is made in compliance with San Joaquin County.ordinance No. 5!9-and 1862 and the Rules and Regulations of San Joaquin County Public Health Se+ices.[..lz � C+ t/ u 6 a . .rl�,.. s 1�2r030 Job Address Rough & Ready Island, NCS Sto„gkton City Lot Size/Acreage1400 nrycq Owner's Name _ U.S. Navy ! Address Rough & Ready Island., SYnrktna- Phone 20 Rancho California Contractor B_ & F Drilling_ Address Cordova License No.51942$ Phone 916 63:i-95 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t:.. DESTRUCTION ❑ put of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER G Monitors Well x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE wells FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E Industrial ❑ Open Bottom C� Manteca Dia. of Welt Excavation _l0r' Dia. of Well Casing 4” Pa' Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC SpecificationsSchedule 80 I'I Aubtic i� Other 6d Delta Depth of Grout Seal 5'-45' Type of GroutCement Benton' t I Irnpauon 50�Approx., Depth AJA"te— Surface Seat Installed by $ & F Drilling Repair Work Done LJ 'Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Death 1 Filler Material & Depth San 10'—901 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION ! I Mo septic sYstam permitted if pubGe sewer as available within 200 feet.f lnstallation will serve: Residence, Commercial_ Other Numoer of living units: Numi.er of bedrooms Character of soil to a depth of 3 feet, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT ALT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE 0 No. & Length of lines Total length/size r FILTER BED ❑ Distance t; nearest: Weil Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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'candies the following: "I certify that in the performance of this work for which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or subcontracting 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." t The applicant must tail for all required inspections. Complete drawing on reverse side. Signed X Title:Geologist/Project Manager Data: 9 FOR DEPARTMENT USE ONLY Application Accepted by ! Datev Arae Pit or Grout Inspection by ]S Dats��— Final Inspeetian by Date 11 i Additional 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 AMOUNT DtJtc + AMOUNT REMITTED14 CK 1 CEIVED 8Y INFO �n Q(] H TE PERMIT NO. EM 13-26 tREV. 1 h 51 0./J'� FW14-26 I vvv 111 "` J V 1 h l�� 13 �� 92.3V3�