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_ _ •�- – _ Vull IM " APPLICATION FOR PEWIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)488-3420 P O BOX 2009, STOCIMN, CA 95201 j (Complete in Triplicate) lApplication is hereby rmde,to San Joaquin County r e a permit to construct arid/or install the work herein, described. This application is Stade in coWliance with Son Joaquin County Ordinance No. 549 and 1862 and the Rules wad Regulationa of Baa Joaquin County Public Health Services. .rob Address 1448 N. E1 Dorado Street City_Stockton Int size/Acreage 1 . Owner,Nama Wickland Pra2erties __ Address 1765 CM11i roe^Wi S nttD• CA .. Phona -'91(1' 921. 1100 _ - - 95650 95815 Canl;auor f_xjate EjpLcz:ation Address VAZ D3=M5 EU, I CA ,Ltceri No.-421530—C-157—Phone 1916'-_d 4kE TYPE OF WELL/PUMPS NEW WELL ,`'. WELL REPLACEMENT f—, DESTRUCTION �i Out or Service We.11 ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C Monitoring 51@11 OISTAttiCE TO NEAREST: SEPTIC TANK NA SEWER LINES 50- DISPOSAL FLO. NA PROP. LINE 15• FOUNDATION 30 AGRICULTURE WELL —LA-- OTHER WELL a-5 PITS/SUMPS N_—A INTENDED USE TYPE OF WELL PROfIi AREA CONSTRUCTION SPECIFICATIONS lindustrial ❑Open Bottom ❑Manteca bis.of Well Escawahon S" Dia,of Well Casing f!Domesuc/Privale 61 Gravei Pack ❑ Tracy Type of Casing__M,Si 40 Storcd cations°Sn cin`�zb—gO 1'1 111 0 other M Delta Depth of Grout Seal 15' Type of Grout I I litigation _Appoa. Depth I i Eastern Surface Seal Installed by Rapti Work Done ❑ Type of Pump H.P. - State Work Done._ Wail Destruction ❑ Wall Dirmelar Sealing lasterial.& Depth Depth Filler F4tterial i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo taphc system permrlod i1 public lower is available within 200 lost.! Installation will serve: Residenca— Commercial_ Other Numbor of living units: Number of bedroom@ r Charactar of snit to a depth of 3 loot: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compatements PKC.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.a Length of linea Total Iangil ize FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Sire Number SUMPS L1 Distance to nearest: Welt Foundation. __ Property line DISPOSAL PONDS ❑ I hereby certify i I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,end rules and regulations of the San Joaquin County Home owner or ficansed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued.1 shat not - employ any person in such manner as to become subject To workman's compensation laws of California."Contractor's hiring or su!-contraci it>C•signature - eertifipthe following."1 certify that in the performance of the work lot which this permit is issued.I shall employ persons sul ct to workmai compansa• tion laws 9f California." The applicant must call for all required InsF ctiana.:omptots drawing on reverse side, SignedX Title: QA'.Pr -- _ Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Data Aras P1t.or Grout_Insftectan.by _Date. -Final.lnspeclion.by. --Data 7.: Additional Comments: 4 APpllceat — Return all copies to, San Joaquin County Public Health _ 4mo, Services, Environmental Eiealth Permit/Services ;.' 1601 E. Haseltoa Ave.. P 0 Box 2009, Stockton. CA 95201 INFFEEO AMOUNT DUE AMOUNT.REMiTTEp -CASH RECEIVED By DATE PERMIT NO. ' - . fit 17•N taiV.t..v - EH 4.2e - -