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DISTRICT liddl.0► HOMO MO AA, OT012006 N; CA .4 ENIIfRONi:'- A�'LTt�' ' i,bifW ill FIs ilgig§S�CRAP!R im;§&r, jai pijj I F,f•!II HgiQiEf;E-4'sffi6i(af R pgrmif f0 6tifigir06f mid/w infifiitf fila;,dark 141 miilpla[iall ' rii"1aA in r:!�fi7Rh9,7F,-Wi€!?,s$,Rn Aortyin cnypty UrAnRnao Na §4'J far AgwR90 6f No, M2 Ipr wall/pump and the Rules and Regulations of the a j,,loaglrita i,gpi gallh fistri�f, ;F.- I. 1: i 1 Job Address 1448 El Dorado Street �-_ City Stacktan Lot Size 290' X 295-1PM I Wickland Properties 1765 Challen e- Wa Owner's Name Address Phone (5)6) 921-11 C0 SaCxamento, CA .95815 contractor HD94--0 g-11UM Address 3242 1ramans rd, 10ani.sI CA License No. 401530 Phone (916)652-4640 TYPE OF WELL/PUMP: NEW WELL 0 W-5 WELL REPLACEMENT 0 DESTRUCTION 0 ; PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 � t 1 DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 50 � i DISPOSAL FLD. N A PROP. LINE 80 FOUNDATION 10' AGRICULTURE WELL NA•• OTHER WELL -50' •PITS/Swpr, _LVA ' INTENDED USE TYPE OF WELL PROBLEM AREA • CONSTRUCTION SPECIFICATIONS CR Industrial Y1X t 1r 0 Open Bottom 0 Manteca Dia. of Well Excavation �- _ Dia. of Well Casing- 411 r i ❑ DomesticAhAe 6 Gravel Pack ❑ Tracy Type of Casing S�ft 40 F'480 PVC Specifications 50-- Benlchite { f M Public fl Other � �� IRI Delta Depth of Grout Seal 25` Type of Grout t a�t I I Irrigation �..Apprax. �epi�i I 1 Eastern Surface Seal Installed by hbS� Lb�o_ Repair.Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Fillet Material (Below 50') ,t`��,t TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/,ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms I. Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0'. Method of Disposal Distance to ()earest: Well• Foundation Property Line ` LINE LI No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: We11 Foundation Property Line G SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: .- WellM 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 laws, and rules and regulations of the San Joaquin Local Health Di1trict. 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 shalt 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 I'- certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." r The applicant must ca/forII r ired inspections. Complete drawing on reverse side. Signed X Title: ,,✓ Date: i; FOR DEPARTMENT USE ONLY i Application Accepted by Date �-9n Area Pit or Grout Inspection t Date Final Inspection by Date l Additional Comments: ' ❑ Stk 466.6781 0 Lodi 369-3621 0 Manteca 8.23.7104 0 Tracy 835-6385 I Aapticant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA.95201 d INFO ,AMOU/NTT DDUE AMOUNfT RREEMITTED CASH RECEIVED BY DATE�1 PERMIT'NO, i •.EN 13.24(REV.1�M by g g, l/�/ 8�'0— EN W2s F r ,