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T APPLICATIONS FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE IS§UED (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. OL© AW �D'C�k b�, �% h Job Address 5930 N. HIGHWAY 99 (E. Frontage -Rd) city STOCKTON Lot Size/Acreage Owner's Name NAT'L TE EPHORE & TELEGRA"ress IR55 SACRAMENTO S Phone (916) 357-4466 Contractor NOACK PUMP COMPANY—_Address 4500E E ONT STOCKTON License No. 504513 Phone 8-8817 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 X.X Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public is Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump 9 UBMEMIBLLH.P. I ISD State Work Done RFM61ilFJPT DIIMD R Well Destruction ❑ Well Diameter Sealing Material & DepthLE PUMP Depth r Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if ptiblic sewer is available within 200 feet.) Installation will serve: Residence Commercial____ Other I -� Number of living units: Number of bedrooms O 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state~law_s, 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 California." The applicant t, a all required , ns. mplete drawing on reverse side. SignTitle: RETAIL SALES Date: 10-17-90 ed FO E`PAARRTMENENT USE ONLY Application Accepted by Data '� Area Pit or Grout Inspection by Date Final Inspection by f Date 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMtTTEO CK I CASH RECEIVED BY DATE PERMIT'NO. Q Q : EH 1321(REV.t i Hsi l(1-1�3-l0 EH 14.25 ! L