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APPLICATION FOR PERMIT 1{I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON., CA 95201 r PENIT EXPIRES 1., YEAR FROM DATE ISSUED 17� (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5L9 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4865 E. EIGHT MILE ROAD City STOCKTON Lot size/Acreage owner's Name ROBERT LINDSTROM ,address P.O. BOX 1952, STOCKTON Phone465-7291 F Conlraclor NOACK PUMP COMPANY Address4500 E. FREMONT, STOCKTON.icense No. 504513 Phone948-8817.w TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l-7 DESTRUCTION ❑ Out of Service Weil L1 PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11J P Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XXDomesti6iPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'} ?ublic is Other n Delta Depth of Grout Seal Type of Grout �! I I Irritlaiion Approx. Depth 1 1 Eastern Surface Seal Installed by ",. Repair Work Done Type of Pump __ CIIRM �RCIBH-P• - 1H .,,, ____ State Work Done —INSTALL EXISTING SUB 'Well Destruction ❑ Well Diameter ` r Sealing Material 3 Depth P11MP IN NEW W1711 _ POUR Depth - Filler Material Depth P.AD____ TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION f I DESTRUCTION I I INoiseptic system permitted if public sewer is a available within 200 feet,) i Installation will serve:-Residence-- _--Commercial- Other -^- _Number of living units: Number of bedrooms ' Character of-soil to a depth of 3 feet: Water table depth SEPTIC TANK. . 0 Type/Mfg Capacity "No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size fi FILTER BED C) Distance to nearest: Well Foundation Property Linef SEEPAGE PITS 11 Depth Sire Number SUMPS Ll 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 of 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 II r quired s ns. C plata drawing on reverse side. Signed X Title: REIAIL SALES Date: 5-3-91 FOR DSPARTMENT USE ONLY } Application Accepted by Date s-_sr _._ AreaZ�Z Pit or Grout Inspection by Date Final 14.pection Additional Comments: r 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. �� . . EN 13-24(Aiv.+>N sl �� - EN 31.20 !!! "`"'"' ,„