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6' 1Sh'l'I It',Al )+_114 1`I,ItlVill NAN J01\ 010 I.M'At. Hi AIATI 013THICT x 1601 1-, t1AT1 {,i ON AW, ;i i lli,fC` ON, CA pISiO� d'�6i�+111"� . l�irwb 1 -t - i --1. 1.1 CRSS t0CNV-E�LJH p J5 _ _...,, .. CC0111131ete in Triplicate).,..�� Application is hereby made to the San Joaquin Local Heallh District for a,permit to construct aigiTf�r Inst Iherein described. This application is made in compliance with San Joaquin County Ortfeiancu No.549 fur sriwapa or No. 1862 fur walilpump a Ehe Rules and Htlgulations of the Sart Joaquin Local Health District. Jab Address DCIL1dX1ICk3lP1�r 20' wt st Oil ibLK.IlaS frau Pacific City�CICton Lot Size NSA --- PM r S•i Owner's Name _ Pegal_—A_ ickland Oil. C_b. -_ Address 1765 Cha1leMe W3yr SRcranaPhone 1to _— (916) 921-110U' Conlractor WeZtErn Cao-PXJI eer•S Address 1� E. St-, `5138`57 (916) 662-4541 License No. Phone TYPE OF WELL/PUMP; NEW WELL X WELL REPLACEMENT 0 DESTRUCTION}Cly PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER', .t3r'WalV l DISTANCE TO NEAREST: SEPTIC TANK N/A—_ SEWER LINES 75' DISPOSAL FLD. NSA PROP. LINE 20r FOUNDATION - inn- AGRICULTURE WELL - OTHER WELL nen.__i PITS/SUMPS _X& INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial !.i Open Bottom 11 Manteca Dna. of Well Excavation 1f1" Dia. of Welt Casing 4'1 :i 0 Domestic/Private L4 Gravel Pack 1-1 Fracy Type of Casing PVC Specifications Fl Public E 1 Other Ota Delta Depth of Grout Seal 30' _ Type of Grout bleat 03TIMt 45 1 I I Irrigation 65.!Approx. Depth 1 1 Eastern Surfdco Seal installed by WEStern �Eq�-r6 _ + " Repair Work Done L3 �- P Type of Pump —� H.P. — _ _ Slate Work Done Well Destruction 171 Well Diameter --.Joel Sealing Material (topV) 30-k neat oment t 5% benbo'ib9 '+ Depth — Gtr' — Filler Material l6oiow 102' #3 1TgAt SaY1C� Q TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I IN septic system permitted if public server Is available within 200 feet.) "`" n Installation will serve: Residence_ Commercial__. (ither Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: _ --"--------•---------.-"-��._ Water table depth i SEPTIC TANK 0 Type/Mfg m -,.—_-- Capacuy_— No, Companinents: i PKG. TREATMENT PLT. 1=1 Method of Disposal U1 Distance to nearest: Weil ___.__ __ Foundation Property Line LEACHING LINE I:1 No. & Length"of lines __. .__. _ Total length/size FILTER BED (-I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth __. _---Sue {.- _ _-_--_ —.._-_ Number SUMPS . I i Distance to nearest: Well __. Foundation Property Line i DISPOSAL PONDS 1. 1 1 V I hereby certify that I have prepared this application and that thtr work will Isu dune in accordance with San Joaquin county ordinances, state lawi,and I > rules and regulations of the San Joaquin Local Health Dislrici. t Home owner or licensed agent's signature certifies the following; "I certify that in the peifonnance of the work for which this permit is Issued, I Shall tot~ employ any person in such mariner 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 tete work for which this permit is issued. sha11e iduo (pnrsOns�suu subject to workman's compensa- tion Paws of California." 'SA JVIRAO(�NMENTAL HEALTH DIVISION r The applicant must cal or all r qtr" s n r fete drawing on reverse side. 1 --. _.._ _ _�. Signed X _- Title: President 5� �6 atPE, FOR DEPARTMENT USE ONLY Application Accepted by _ ^' �--------- .___.. Data `trJ`7 Area r ''� _ Pit or Grout Inspection by — Qat�,p�y'�=—� Final Inspection by Data-4019-L_ Additional Comments: © Stk 466-6781 0 Lodi 369-3621 0 Manteca 823.7104 — C} Tracy 835-6385 Applicant- Return all copies to: Environmental Hoalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 EEE AMOUNT DUE AMOUNT REMITI RECEIVED BY DATE PIERMIT•NO. INFO _ *-Eh 13.24 MEV.+�x er i1 b S: 3