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APPLICATION FOR FERMI r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZEL T ON AVE , S1 OCKTON, CA Telephone (209) 466 6791 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit so construct and/or install the work herein described This application is made in compliance with San Joaquin County Ordinance No 549 for sewage or No 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District Job Address 6425 Facif-tc 7wenue City Stockton Lot $1e 130' X 1 50'PM Owners Name WICKLAND PROPERTIES Address P.O. Bok 13648,Sacranwto, CA 9585p-6tJW (916) 978-2485 94571 71009 C-57 (707) 374-430 Contractor L� DRILLING —Address 1S-n_ FnX 31S Rin Vi4 A- CA License No Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 29SEId- 1e B=11119S SEMM, t DISTANCE TO NEAREST SEPTIC TANK N/A SEWER LINES 60' DISPOSAL FLD N1A- PROP LINE 3.:_�. FOUNDATION 2d' AGRICULTURE WELL N A OTHER WELL 27' PITS/SUMPS NIA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing 6 Domestic/Private Cl Gravel Pack Cl Tracy Type of Casing Specifications f 1 Public I-R Other SAP9PLE ECPJNMtta Depth of Grout Seal Type of Grout I 1 Iri,gat,on 65' ApproK Depth I I Edstern SisrfaCe Seat 1nStdilad by Repair Work Done L3 Type of Pump H P State Work Done _.,_. Well Destruction O Well Diameter Sealing Material Itop 50 I Neat cernent with (5% Baitxxaba Depth Filler Material l8elow 50 j Neat CaTEnt W1.th 5% BPlltXMt]e TYPE OF SEPTIC WORK NEW INSTALLATION I I RIPAIR'ADDITION I 1 DESTRUCTION I I INo septic system permitted d public sawer is available within 200 feet j 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 Cl Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE M No & Length of lines Total length/size FILTER BED El Distance to nearest Well ___ Foundation Property Line SEEPAGE PITS 11 Depth Size _ _ Number SUMPS I I Distance to nearest Wcu Foundation Property Line DISPOSAL PONDS n - 1 I hereby certify that I have prepared this application and that the wcfk %dl be done ,n accordance with San Joaquin County ordinances,state laws, and rules and regulations of the Serf Joaquin Local He9fth District Home owner or licensed agent s signature certifies the following I certify that in the performance of the work for which this laeirtut is issued I shall not employ any person in such manner as to become subject to workman s compensdtion laws of California Contractor s hiring or sub-contracting signature cenif+es the following 1 certify that in the performance of the work for uh,ch this permit is issued f shall employ persons subject to workman s compensa •son laws of California ' The applicant must for I r ed s omplete drawing on reverse side -59 Signed X Title v Date FOR DEPARTMENT USE ONLY Applicatten Accepted by r I � Data Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments ❑ Stk 466 6781 ❑ Lodr 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 Applicant Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave , P O Box 2009, Stk, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO • Eri is lliErr ,,.,, �5q �J.23-`� b 125 yg EN t4M