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� .rl -..Wl .. 0 s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON AVE , STOCKTON, CA Telephone (2091 488.6181 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J (Complete In Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct aAdpump and the Rules and ol Install the work in u cubes o the SanThris ication is JoWutn made in compliance with Son Joaquin County Ordnance Nu 549 rot sdwage of fro ltlb2 for wtil g Local Health District Job Address .,r_ 6425 Pacific Avenue City Stockton Lot Size 240'X260' PM Owner s Nama Wickland Oil Company Address 1755 Q-Iallerx)e V13Y' Sa=Wrlent0' CA 9581 hone(916) 921-1100 Conitacitx Western Geo em Address 1386 E. %wer St License No 513857 phone (916) 662-4541 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ID Nbnitcr Lil&U DISTANCE TO NEAREST SEPTIC TANK N/A — SEWER LINES _50' DISPOSAL FLD Ma PROP LINE NLA— FOUNDATION AFOUNDATION NZA AGRICULTURE WELL N/A OTHER WELL N 'a PITS/St.tjAPS N�'A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom 0 Manteca Dia of Well Excavation 1Q" Dw of Well Casing 4ii ❑ Domaslic/Private (R Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public (1 Other Q Delta Depth of Grout Seal 20' - Type of Groul Neat Cement I 1 Irtigatron 65' Approx Depth t I Eastern Surface Said installed by tt Prn QX2= � - Repsu Work Done U Type of Pump _N/A___T H P State Work Done _ Well Destruction ❑ Well Diameter 4" Sealing Material itop 50) Neat al=t -- Depth 65' Filler Material (Below 50'1 TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/,ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is avadabla within 200 feet 1 Installation will serve Residence— Commercial __ Other Number of living units Number of bedrooms Characleiof sod to a depth of 3 feet Water table depth SEPTIC TANK f_l Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ 1 Method of Disposaf Distance to nearest Well Foundation Property Line LEACHING LINE Ll No 8 Length of Imes Total length/size FILTER BED Li Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 11 Distance to nearest Well Foundation Property Line DISPOSAL PONDS I 1 I hereby certify that I have prepared this applwation and that the work will be done in accordance with San Joaquin County ordinances state laws, and rules and regulations of the San Joaquin Local Health D3tnct Home owner or licensed agent s signature certifies the following I certify that in thin performance of the work for which this permit is issued I Shall not employ any person in such manner as to became wblect to workman s compensation taws of California Contractor's hiring or sub-contracting ignaturn cane ies the following I certdy thba in the performance of the work for which this ptiffml is issued I shall employ persons subject to workman s cormpenaa tion taws of California ' The applicant met call for all a ad Inspections Complete drawing on reverse tide Sig Title VIM p»gidiant Data 1/11/89 George Oial _ FOR DEPARTMENT USE ONLY Application Accepted b Lite Arra Pit of Grout Inspection by Data Final Inspection by Data Acidnional Comments TStk 466 6781 ❑ Lodi 369 3621 EJ23- Manteca 87104 ❑ Tracy 835 6385 pplicant Return all copies to Environmental Health Permit/Services 1601 E Hazeflon Ave , P 0 Box 2009, Stk , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT No INFO tw5H