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} <br /> APPLICATION- FOR PERMIT <br /> 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RMIX EXPIRES 1 YEAR FROM DA ED <br /> (Complete in Triplicate) . Q —o/ <br /> t to construct and/or install the work herein described. This <br /> Application is hereby made to San Joaquin County for a permi <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 s.nd the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> WEST SIDE OF HANSEN ROAD — 250 YARDS TRACY Lot Size/Acreage <br /> Job Address City- <br /> Owner's Name <br /> SAFEWAY , INC. Address 16900 sc40tte, TRACY 95376 Phone <br /> i Contractor <br /> 'NOACK PUMP COMPANY A4iess4500 E. FREMONT STKN License No. 504513 Phone 948-8817 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TAiNK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> r, <br /> INTENDED USE r TYPE OF WELL PROBLEVAREA CONSTRUCTION SPECIFICATIONS <br /> EI Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X1 Domestic/Private ❑ Gravel Pack D Tracy - Type of Casing Specifications <br /> i i'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 ^Type of Pump H.P. I State Work Done DESTROY 6 DOMESTIC p <br /> Well Destruction CJ Well Diameter[�7� eating & Dept DRY. Q� <br /> Oe ih c3,�) Filler Material & Depth �J <br /> p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCT o septic sys(em•permitted if public sewer is <br /> i available within 200 feet.)' <br /> Installation will serve: 'Rssidence— Commercial_ Other. / <br /> Number of living units: U Nurr berof bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Y Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT: ❑ } Method•of Disposal <br /> —- Distance to nearest: Well Foundation Property Line <br /> J. R '.+ <br /> a ll <br /> LEACHING LINE Cl" No. & Length of linesTotal length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation ri Property Line _ r <br /> ° <br /> SEEPAGE PITS lIl_ Depth Size Number <br /> I SUMPS 10 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> 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, . <br /> Y rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that)n`the.performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued'l shall employ persons subject to workman's compensa- <br /> tion law, mia." . <br /> The applicant mus al o all re ons. Complete drawing on reverse side. <br /> Signed YLO . : Title: RETAIL SALES 1 .pate: Z/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedby Date A <br /> Pit or Grout inspection by Date Final Inspection by Dab✓ S <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FfE AMOUNT-DUE AMOUMT REMITTED CASK RECEIVED 13Y DATE PERMIT'NO. <br /> � INFO // <br /> ! + EH 1344 1REV.t/n s° !�. <br /> EH 14.20 D. --- <br /> .� w <br />