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r 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 PERMIT 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 21111 S. AIRPORT WAY City MANTFCA Lot Size/Acreage Owner's Name GIACOMO LONGO Address 21111 S AIRPORT WAY, MANTECA Phone239-2743 Contractor NOACK PUMP COMPANY Address 4500 E. FREMONT, STOCKTONIicense No. 504513 Phone948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION MX 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X)(Pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public fl Other (1 Delta Depth of Grout Seal Type of Grout ._. I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by ._ Repair Work Done U Type of Pump 1-1/2 HP H.P.SUBMERSIBLE State Work Done_ REPLACE JET PUMP Well Destruction ❑ Well Diameter Sealing Material & Depth WITH, clnzMERSIBLE Depth Filler Material & Depth PUMP ` 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 g Number of living units: Number of bedrooms 7 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 Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 followin : "I certify that in the performs ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C t ornia. The applicant mu call r uir . Complete drawing on reverse side. Signed YL Title: RETAIL SALES Date: 10-9-90 (� FOR DEPARTMENT USE ONLY ` Application Accepted by _ V �1Cle� Date \V—1 — RL Area l Pit or Grout Inspection by Date Final Inspection b Date�� 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH AECEIV By DATE PERMIT'NO. elf . EH13.2 IREV.iinSl /j ` G/- �Il �)��EH t1.2edq, y(� v(