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APPLICATION FOR. PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC FMA-LTH SERVICES <br /> ENVIRONMENTAL I:EALT11 DIVISION <br /> 1601 E. ffAZELTON AVE. , PHONE (209)1468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMLI EXPIRES 1 YEAR FROM DATE ISSVED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fa, a permit to construct and./or install the work herein descril~ed. This <br /> application is made in conpliance with Can Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sari <br /> Joaquin County Public Health Services. <br /> Job Address fll 475 W. BLEWETT ROAD __.._ city_TRACYLot size/Acreage <br /> Owner's Name C&A RAVARRA RANCH Address 475 W. BLEWETT ROAD, TRACY Phone 836-0005 — <br /> Contraclnr NORCK PUMP CO. Address 4500 E._ FRE [ONT , STKN _ License No. 504513— T Phone 048-8817 <br /> TYPE OF WELL/PUMP NEW WELL El WELL REPLACEMENT M DESTRUCTION I Out of Service Well �-i <br /> PUMP INSTALLATION SYSTEM REPAIR C7 OTNER Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _-_ DISPOSAL FLD. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LI Industrial El Open Bottom Ci Manteca Dia of Well Excavation ___ Dia. of Well Casing _Domestic/Private D Gravel Pack Cl Tracy Type of Casing_ Specifications <br /> Public - I 1 Other (7 Delta Depth of Grout Seal Type of Grout <br /> Xi Irricjation ____ Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done i_7 Type of PumpTIIRRTfJ1- H.P. 100 State Work pone — INSTALL_1I1RBIJlE_ PUMP <br /> Well Destruction ❑ Well Diameter sealing Material & Depth 7 �1�! 1�IpLL f <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I l REPAIRIADDITION i i DESTRUCTION i l SNo septic system permitted if public server is i✓�" <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Comrner6al ..— Other ................... I f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: table depth <br /> SEPTIC TANK C] Type/Mfg _.-- Capacity —_ No. Compartments <br /> PKG. TREATMENT PLT. L] Method of Disposal <br /> Distance to nearest: Well Foundation __ Property Line <br /> LEACHING LINE ( ? No. & Length of lines Total Iangth/size___ —�.. <br /> FILTER BED (7 Distance to nearest: Well Foundation - Property Line <br /> 4— <br /> SEEPAGE PITS Il Depth --..Size Number ' <br /> SUMPS L-I Distance to nearest: Well f=oundation Property Line <br /> t <br /> DISPOSAL PONDS El { - <br /> I hereby certify that I have prepared this application and that the work will be bone in accofdancc: with San Joaquin county ordinances, state laws, arrd <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the pftlwmanco of the work for which this permit is issued, 1 shalt nol <br /> employ any person in such manner as to become subject to workman's compensation Ian-ys of California." Contractor's hiring or subcontracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issoad. I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appfic�nt ;uSt it for all squired ti t millets drawing on reverse side. <br /> s=.gnsd x DI "OR Title: _ RETAIL SALES Date: Y. -.. <br /> J <br /> FOR DEf=ART;"ReNT USE ONLY <br /> Application Accepted by Date .— ''�/ Area <br /> Pit or Grout Inspection by Data — —___ Final Inspection by Pa = Date <br /> Additional Comments: <br /> Applicant - Return all. copies to. Ss•xf Joaquin County Public Health <br /> Services, Environmental health Peraat/5erv1cec <br /> 1601 E. Raselton Ave., P 0 Box 2005, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT flEMITTED CK x RECEIVED BY DATE PERMtl' NO. <br /> CASH <br /> E0t _. <br /> £ht 1124 JREv. •n 5. - \. 5 � <br />