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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IWI E HAXELTON AVE STOCKTOfd, CA 'telephone 0081 466 6781 PIAMIT 2XISI198111 1 VIRAA FROM DATE 118911JED (Complete in Triplicate) Application is her eby mala to the San Joaquin)pea!Health Distrrc[for a permn to construct endrin install 411e work herein described This application is t made in compliance with San Joaquin County Ordinance No 549 for sewage or No 1662 for wellipump and the Rules and Regulations of the San Joaquin Local Health District Job Address -1448 N. E1 Dorado_ Street_ – City Stockton Lot Sise 120, X 120' i - _ PM— Ownershame Wickland Oil Company (916) 921-1100 Address 75 CaengeYr S�crarsn Cp_ Phone 95695 { Contractor ��n Address 13B6 E. Bmmr St.r �� i License No 513957 Phone 6 6624541 +YPE OF WELL/PUMP NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION L1 j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 6 V-'1;='ttMit3 DISTANCE TO NEAREST SEPTIC TANK SEWER LINES 50' DISPOSAL FLU WA - PROP LINE 60' I T FOUNDATION 15 AGRICULTURE WFLL -._. — OTHER WELL NEA PITS/SUMPS to i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I fS Industnal t"17salbcw ❑ Open Bottom ❑ Manteca Dia of Well Excavation 3641 Dia of We11 Casing 4�° ❑ DorrlesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing F 480 PVC Sch 40 Specifications f"1 Public Fl Other rl Delta Depth of Grout Seal 6' Typs of Grout NRt 03mTt j I I Inrgalwn — Approk Depth I I Eastern Surface Seat Installed by _ # Repair Work Done L7 Type of Pump H P State Work Done i Well Destruction ❑ Well Diameter Sealing Material(top SO) Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRlADOITION i I DESTRUCTION I 1 lNo septic system perrrutled if public sewer is available within 200 feet 1 Installation will serve Residence_ Commercial__ Other Numbs-of living units Numlxr of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to neatest Well Foundation Properly Line LEACHING LINE 0 No A length of tines Total length/sue FILTER BED ❑ Distance to nearest Well _ Foundation Property Lind-_-_- SEEPAGE PITS 11 Depth Sue �_ Number SUMPS LI Distance to nearest Well_ Foundation Property Line DISPOSAL PONDS ❑ 1 hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws and rubs and regulations of the San Joaquin Local Health O3lrict Home ownef or licensed agent s signature certifies the following I certify that in the performance of the work for which this permit is issued I shall not employ any parson in such manner as to become subject to workman s compensation laws of California"Contractors hiring at sub-contracting signature cartiftes 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 compansa tion lawns of California" The applicant mus for r s mplete drawing on reverse side Signed7ionAccompted Title lfit (�7 #513857) _ Date 12/28/89 FOR DEPARTMENT USE ONLY Appkby date Area Pit or Grout inspection by Date_ _ Final Inspection by Data Additional Comments ❑ Stk 46-MI ❑ Lodi 369 3621 ❑ Manteca 623 7104 ❑ Tracy W6-&3ft Applicam Return all copies to Environmental Health Permit/Services 1601 E Haxeiton Ave, P 0 Box 2009, Stk , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH REtEiYED BY PATE PCcRM1T NO {rilFb + !A liar tN(V r r x 6i 4M 1426