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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1$01 E. HAZELTON AVE. , PHONE (209)458-3420 P O BOX 2009, STOCKTON, CA 95201 D UIT EXPIRES 1 YEAR FROM DATE ISSUM (Complete in Triplicate) Application its hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Union Island !!`!- ° ity Tracy Lot Size/Acreage N/A I Owner's Name Various Address As per attached ma Phone Western Geophysical Co. P. O. Box 81915, Bakersfield, Ca. 805 324 0340 Contractor Address License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XX Monitoring Well C7 I 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 11 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I1 Public RMXR%t OralF1 Delta Depth of Grout Seal Type of Grout I I Irrigation I I Eastern Surface Seal installed by Repair Work Done ❑ Tmp HSP. State Wor one ; Well Destruction ❑ Well Diameter Sealing Material & Depth ement�Bentonl e S carry or Depth tt Bentonite w tremie pipe TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR tAt)DITIOI IJR 10f CTI I 1 rmitted if public sower is , E ;ails it tt int. eet.l r Installation will serve: Residence— Commercial_ Other �Y have expired without Number of living units: Number of bedrooms t, y,�i� Character of soil to a depth of 3 feet: work b CQ.MQIPtPd Qr 1rf8VUdiMVd,pth SEPTIC TANK. ❑ Type/Mfg k" '. tf f Compartments PKG. TREATMENT PIT. ❑ �VIeDisposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED EI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number i SUMPS C; 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." Contractor's 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed x Title: Permit Agent Date: 12-21-90 James P. Dee DEP RTMENT USE ONLYApplication Accepted byDate �` a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1641 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO i CASH I` } + EH 13.241 REV.Iin5) �"7 (01r <—;� /Z !/� u j EH 96211 U / lit