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APPLICATION FOR FERMI f SAN .10Af:)<MNi' LOCAL t AL.TH 01STRIC+T � 1601 �111AM:t.TON AVE.; S I Oi KTON, CA c €�'% ' '• !1§It?151t1.t11� �s`'.(It�l �"I�tt'3 fi�#S1 µEQ+ �ojt ! f�1��fIN9t�'�� )''MES 14tifK 1' 010 DA SSu L�G�t�1EPV�� [ ofrtpkt3to in Triplicate) N ,�,33)�J0ofi"h!• ��' Application is hereby made to the San Joaquin Loral Health District for a permit to construct atrt(9Y�r�ins tl� ork herein described.This application is made in compliance with Sari Joaquin County Ordinance No, 549 lur sewage or No. 1862 for well/pump and the Rulers and Regulations of the San Joaquin Local Health District. i Job Address . x 1 320' west on las from Pacific City_�1 Lot Size NSA PM 4 Owner's Name Regal _A Wickland Oil m- Address 1765 Challer-98 ii�y, SaCr'iKsitO Phone (916) 921-1100 Contractor Vtstern eerS Address_1� E. �•, t"�� License No. `13$57 Phone(916) 662-4541 Cho-�xti TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION Cl 1 PUMP INSTALLATION ❑ SYSTEM REPAIR I-] OTHER & NbiliitOr 4Abl.1 DISTANCE TO NEAREST: SEPTIC TANK til/A—_ SEWER LINES 751_ DISPOSAL FLD, NSA PROP, LINE 20r r FOUNDATIONi(lClr _ AGRICULTURE WELL OTHER WELL—00-- PITS/SUMPS hVA r — - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial f I Open Bottom 1_1 Manteca Dia.:of Well Excavation 10" Dia. of Well Casing 4" © Domestic/Private IX Gravel Pack C1 Tracy Type of Casing PVC Specifications I'l Public Ll Other N Delta Depth of Grout Seal 30' Type of Grout Neat ommt +5"cent C I I Irrigation r Approx. Depth I I Eastern Surface Seal installed by mo �E 3179E te=t t 6c Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter '.Orr Sealing Material Itop�) 30'' n9at offnent. + 5% bignb ite Depth 65, Filler Material (Belo-K 30' #3 tTX)Tt Sand TYPE OF SEPTIC WORK: NEW INSTALLATION I I RLPAIR/AUDITION I I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial.—_ Other _ If Number of living units: Number of-bedrooms __ i' m 6 Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK Cl Type/Mfg A Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: I _ Foundation _— Property Line LEACHING LINE 11 No. & Length of lin s __._ —___._.—___ _-_ ____ Total length/size— FILTER BED LJ Distance to nearest: Wei; Foundation _____ Property Line SEEPAGE PITS i I Depth —,Size _.....__--___—_—_ Number SUMPS [ I Distance to nearest: W,!li _ Faundation _--__ Propony Line DISPOSAL_ PONDS I] hereby eenity that I have prepared this application and that the work will bu dUne 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 rho perlorrnanee 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." SAN )OAQUIN LOCAL HEALTH DISTRICT The applicant must fora re c S. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIVISION Signed X Title: — President SPE(CIAIDrRW` /89 FOR DEPARTMENT USE ONLY Applicat' n Accepted by �_.__-_--,- Date vel fo1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 LJ Manteca 823-7104 L-) Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO s.EH 13.24 tftEv,r i rr 51 Auto 1� EH 14.26 0