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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 j <br /> PERMIT EXPIRES 1 YEAR FROM DA ED <br /> (Complete is 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 622 N. WINDSOR CitySTOCKTON Lot Size/Acreage <br /> ABDUL KARIM622 N. WINDSOR, STKN, 95205 Phone 462-2534 <br /> Owner's Name Address <br /> Contractor NOACK PUMP COMPANY Address 4500 E. FREMONT, STKN License No. 504513 Phone 948p8817 <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT D DESTRUCTION C1 Out of Service well Cl <br /> PUMP INSTALLATION U <br /> SYSTEM REPAIR D OTHER D Monitoring Well C7 <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 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications <br /> II Cl Public f..1 Other fl Delta Depth of Grout Seal Type of Grout <br /> t I IfriCalion _....., Approxi Depth .. l I Eastern Surface Seal Installed by <br /> Repair Work.Uone�C]..,�_7ype of Pump_31aMF_RS1BLEH.P-•. <br /> ' ,State Work.Done-INSTAf 1 STIR P11MPIN <br /> w.,Well Destruction D Well Diameter Sealing Material Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 teet.I <br /> Installation will serve: Residence_`Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK. D Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. <br /> El <br /> of Disposal <br /> Distance to nearest: Well Foundation r Property Line ' <br /> i LEACHING LINE D 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 CI Distance to nearest: Well Foundation Property Line <br /> f DISPOSAL PONDS D <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 /> 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 California." <br /> The applicant must c I for all eq r tnspe s. Compl cawing on reverse side. <br /> Signed DI'C Title: RETAIL SALES Date: <br /> OR DEPARTMENT USE ONLY <br /> ! t Area <br /> t Application Accepted by Date l <br /> Pit or-.Grout inspection by Date Final Inspection to Dace <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 /> F FEE AMOUNT DUE AMOUNT REMITTED-71 CASH RECEIVED BY DATE PERMIT'ND. <br /> a EH 13-24(REV. INFO <br /> t i n 5l <br /> EH i4-28 <br />