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j I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 ft. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ° (Complete in Triplicate) 1 Application is heiebY made to the San Joaquin Local Health District for a permit.lo construct and/or install the work herein described. This application is made in compliance with San Joaquin Country Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District, 6425 Pacific Twenue city Stockton Lot Size 13Q' X 150'PM Job Address WICKLAND PROPERTIES Address P.O. Box 13.648,SaCxM-01t0, CA 95858 (916) 978-2485 Owne+'s Name 94571 71009 C-57 (707) 374-430 Contractor ytDClafrlARD DRILLING- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ le B'�l.M SP4, ,& PUMP INSTALLATION [DSYSTEM REPAIR ❑ OTHER I'll t DISTANCE TO NEAREST: SEPTIC TANK NSA SEWER LINES C�0` DISPOSAL FLD._N/A - PROP. LINE 3 . FOUNDATION 20' AGRICULTURE WELL N/A OTHER WELL 27` PITS/SUMPS NZA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Specifications Dia. of Well Casing ff Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing f1 Public (R Other EAMPLE Ita Depth of Grout Seal Type of Grout .— I t hrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Dont L1 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Nkat Ott with 5% ltc�tit]e Depth Filler Material IBelow 501 Int cenMt With 5% BentCnibe TYPE OF SEPTIC WORK. NEW INSTALLATION I i REPAIR?ADDITION I I DESTRUCTION I I (Noilabseptic systithinem rented it public sewer is avale :s Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ it Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size - _-_^� Number SUMPS l-1 Distance to nearest-. Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work well be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sart Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I cenify 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 must for II r red o S. Complete drawing on r reside. Signed Title: _ Date: R DEPARTMENT USE ONLY �j y Application Accepted by Date ✓ r Pit or Grout Inspection by Data Final Inspection by uste A Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7165 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 0l FEE ' AMOUNT DUE AMOUNT REMITTED CK 2 CASH RECEIVED BY DATE PERMI7'NO. INFO + 1H 13.24 IREV.r i N sr � �✓ _ 5•Z-.J��-yy } EH 1426 t