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APPLICATION FOR PERMIT <br /> 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 /> RERMIT EXPIRES„1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City- ST= ON Lot Size/Acreage <br /> Owner's Name LODI FARMING (SAN TOMO PffiTgERS) 11292 N. ALPINE, STOCKTON <br /> Phone 948-4022 <br /> Contractor NOACK PUMP CO. Address 4500 E. FREMONT STKN License No. 504513 Phone 948-8817 <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION RIX SYSTEM REPAIR ❑ OTHER ❑ 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 /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public CI Other n Delta Depth of Grout Seal Type of Grout <br /> XI Irrigation — Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump ZIIRRTNF H.P. 75 State Work Done _ INUALL TURBINEPUMP <br /> Well Destruction O Well Diameter Sealing Material & Depth IN NEW-WELL. a r(\, <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other r�f1 <br /> Number of living units: Number of bedrooms 1 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> )5� <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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of C ia." <br /> The applicant m t ca i requi�- Complete drawing on reverse side. <br /> Signed x YLOR Title; RETAIL SALES Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date_Q'2 Area <br /> Pit or Grout Inspection by Date Final Inspection by r5 Date <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 /> FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> �INFO GASH <br /> + EH 21)RSV.rinse <br /> A- <br /> EH 4�2e <br />