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. AP111 WATION 101i I't-ijivil l SAN .10At}AN LOCGA1. 1ILALTH DISTRICT 1tiL31 ! EI+ xC;,`I'C}1V /AVF-, SIOCK'T0N, CA t t9119) +�tit,►.!)'!Ef l p1S j .trfY1I1I]atll Irl 1 flt)Iitllllt,) �� Qp,{C]ZNM�N�AL Application is hereby made to the Sion Jelaquin Local Heulth Dietrlct Int a hermit 10 canitruct an of�,b�a��t�� meF81n described. This application is made H compliance with San Joagwin County Ordinance Nil, 549 for serwage w No. 1862 for well/purrip and th res and Regulations of the San Joaquin Local Health District. I Job Address - 7t--9C' rNt"th—Of P2: IJlw & 20' Fast Of I C1f]C Cit Sf OCkbpll f _— y Lot Size N/A PM Owner's Name Y A Wickland CLi1 Ob. Andress ?76?Cha1Z Sa=a,ento — Phoria (9 16) 821-1100 Contractor R�Stjern Gpo- A 1386 E. B2a Phone(916) 662-4541 ! --� Address rtzr St., 4t4ocZatrl License NS,13857 TYPE OF WELL/PUMP NEW WELL lJ WELL REPLACEMENT i] DESTRUCTION ❑ } PUMP INSTALLATION L7 SYSTEM REPAIR ❑ OTHER PZ H.W. DISTANCE TO NEAREST: SEPTIC TANK _ N!�A SEWER LINES 50' - DISPOSAL FLD, N/A PROP. LINE N/A FOUNDATION NSA AGRICULTURE WELL NSA OTHER WELLtn- PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom [ I Manteca Dia. of Well Excavation_ I(I x, ❑ Domestic/Private 0 Gravel PackDia, of Weil Casing --!V- * " I ) Tracy Type of Casing ('1 Public I-1 OtherXI DeSpecifications Delta Depth of Grout Seal ._ 30� Type of Grout�gt-} I I Irrigation ___ Approx. Depth I I Easturn Surface Seal Installed b -5A-bWbX Wey-...._.in1m1etT1 GxbFSrg-i nrxmm- Repair Work Done U Type of Pump WP. __ ___ State Work Done T, —� Well Destruction O Well Diameter �LQ' Sealing Material Ito,, w] 00I DepthFiller Material (Below 9o') (30') #3 mriter sand TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION ! I DESTRUCTION t I (No septic system permitted if public sewer is InstalEation will serve: Residence— Commercia]_-__ Olher Number of living units: Number of bedrooms �� available within 200 feet.) Character of sail to a depth of 3 feet: SEPTIC TANK l_] T —�` -- Water table depth Type/Mfg -- -- _- � Capacity. No. Compartments r{71 PKG. TREATMENT PLT. Ll ►/• Mdthod of Disposal Distance to nearest: Well ___� . Foundation _ Property Line LEACHING LINE L I No. & Length of lines _ .., _ _ _ Total length/size- FILTER BED C) Distance to nearest: Well _ Fouridauon _ Property Line SEEPAGE PITS f I Depth —,Size _._ - - l—_- T_ Number SUMPS I I Distance to nearest: Well -__.__ _ .._ Foundation _ Property Line t` DISPOSAL PONDS {'I I hereby certify that I have prepared this application and that the walk will bt) dr,rte In accordance with San Joaquin county ordinances, state laws,'and rules and regulations of tho San Joaquin Local Health Disinci. Home owner or licensed agent's signature cerlities the tollawIlly: "I certify that in the rwrformance of tho work for which this permit is issued, I shall not employ any person in such manner as to bacome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foilowing: ,I C ify that in the performance of the work for which this permit is issued, I shall emplo�p r�q N tion laws of California." SAN ]OAQEJIN T6reA The applicant mus all for II r ct� n Complete drawing on reverse; side. ENVIRONMENTAL HEALTH DIVISION Signed X Title: _ President SPECIAL PER Tis9 -- Date: FOR DEPARTMENT USE ONLY Applic ion Accepted by �—._ —_---- —_ Dare Sc� Area Pit or Grout Inspection by _ 0ate _.��_ Final Inspection by Additional Comments: O Stk 466-6791 ❑ Lodi 369-3621 D Manteca 823 1104 1-1 Tracy~ 1135-6385 Applicant - Return all copies to: Environmental Health Permit/Somwos 1601 E. Hezefton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEp INFO RECEIVE,, BY DATE PERMIT NO. r-EH 13-24[REV.B ri no EH 14-25 , '>S7 'LitS .ti