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r• a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERRMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6413 ASHLEY LANE City STOCKTON Lot Size/Acreage Owner's Name JUDY SWEETER Address 6413 ASHLEY LANE Phone 931-5053 Contractor NOACK PUMP COMPANY Address 4500 E. FREMONT, STOCKTQKense No. 504513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION Q(X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XX Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public (-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump SUPIMPRSLBLEH.P. 1HR State Work Done_RERI ACE FX SITNG PUMP Well Destruction ❑ Well Diameter Sealing Material k Depth AND EXIEENE) tart t "ASING ABOVE Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 Califor ' . The applicant must call or all r q inks e to drawing on reverse side. Signed I AYLOR Title: RETAIL SALES Date: PARTMENT NLY Application Accepted by0'. . A�7�_ .=� Date 16 ^'r C� Area r� Pit or Grout Inspection by Date Final Inspection byS��s ?/1.d�7� Date J �6 Additional Comments: 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 FE A NT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0.l� + EH 21(REV.r i n s1 A- EH;�Ze vv