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l APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 5;7q a O Job Address•+4'r0 E HA EY LAN City LODI Lot Size PM Owner's Name COLOR SPOT AMEBIC Address 4500 E. HARNEY LANE LODI CA Phone 333-0235 Contractor NOAC:K PUMP CO_ — Address 4500E FREMON, STOCXT.0-N-icense No.304513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION IXX PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing lxpmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Wdrk Done PUMP N WFI I ETI I ER Well Destruction Well-Diameter� -rte earng Material{top 5011ALL 9—SACK SAND S URRY TO TOP Depth Filler Material {Below 50') — C TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 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 l I Depth Size Number SUMPS Cl 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 Local Health District. 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 Californi The applicant must cal 4 all r quired i petit Co>m drawing on reverse side. Signed X R ��!ll��r Title: RETAIL SALES Date: �d NOACK PUMP COMPANY F DEPARTMENT USE ONLY Application Accepted by Date 1 - Area Pit or Grout Inspection by Date ` Final Inspection by l Date 6 � Additional Comments: Vt2 � �i h � 1�'r �tv_ W 3-C D � �(. o~ e �r-i ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �� , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520,�/ � FEE UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NA, INF CASH + —L/7,1EH 17-24(REV.r i n 5Y EH 14-26 /r l/