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APPLICATION FOR PERMI f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZE T ON AVE , S1 OCKTON, CA Telephone (209) 466 6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described TNI;application is made in Compliance with San Joaquin County Ordinance No $49 for sewage Or NO 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Drs nct Job Address 6425 Pacific Ivenue City Stockton Lot Size 130- X 150'PM WICKLAND PROPEFTIES Address P.0 Box 1364E,SacranMto, CA 958 8 (916) 978-2465 owner t Name 94571 71009 C-57 (707) 374430 Contactor y�1W ARD DRIILING Address License No Phone TYPE OF WELL/PUNiy NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ® S=le BXuligs SE-4s r DISTANCE TO NEAREST SEPTIC TANK Nip` SEWER LINES DISPOSAL FLD MIA- - PROP LINE FOUNDATION 20' AGRICULTURE WELL _NZ&— OTHER WELL 27 PITS/SUMPS W-A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia ' Industrial U Open Bottom 0 Manteca Dia of Well Excavation Sp oecrifcauons Well Casing 1016 Domeslic/Prtvale C1 Gravel Pack C1 Tracy Type of Casing f 1 Public [R Other SM41E H Ila Depth of Grout Seal Type of Grout I I IrrNJdtion ' Approx Depth I I Edsteln Swlace Soil Installed by - Repair Work Done U Type of Pump H P State Work Done Well Destruction O Well Diameter ,�� Sealing Material (top 50 1 Nt<atr t wit=h <5% &eltgnite Depth Filter Alaierial lBelow 50 F %at cement With 5% Bmtout7e TYPE OF SEPTIC WORK NEW INSTALLATIO, I I REPAIR rADD1TIOV ; I DESTRUCTION I 1 ave laWdtr thin 20tem 0 fee r!ed it public sewer is Installation will serve Residence — Commercial—_ Other Number of Irving units Number of bedrooms Character of sort to a depth of 3 feet Water table depth SEPTIC TANK 0 Type/Mfg Capacity No Companments PKG TREATMENT PLT [-1 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE C1 No 8 Length of InnesTotal length/size FILTER BED ❑ Distance to nearest Welt Foundation Property Line SEEPAGE PITS I I Depth Sue _ — Number SUMPS i I Distance to nearest well � Foundation Property Line P DISPOSAL POthat C1 I hereby LPOeritly that I have prepared this application and that rhe vticrk vtdl be rtone in accordance with San Joaquin county ordinances slate laws and rules and regulations of the Seo Joaquin Local Health Dutriri Home owner or licensed agent s signature certifies the fOI1Ov+rst9 I Cenrfy that in the performance of the work for which this permit is issued I snarl not employ any person in such manner as to become subject to�%crLrnan s CGmpe1115dtion laws of California Contractor s hiring or sub-contractrng signaiiie cendies the following I certify that in the performance of the% prk for w"iiCh,his permit is issued I shall employ persons subject to workman s compensa tion laws of California The applicant must for I r ed s omplete drawing on reverse srd �/ Signed X Title Date FOR DEPARTMENT USE ONLY Data Area Application Accepted by Pit or Grout Inspection by Cale Final Inspection by Date Additional Comments ❑ Stk 466 6781 O Lodi 369 3621 0 Manteca 923 710,4 0 Tracy 835 6385 Applicant Return all copies to Environmental Health Parrrut/Services 1601 E Hazelton Ave, P O Box 2009, Stk , CA 95201 ` ✓�� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEAtitti NO INFO . t,itaua& It.,, q 5.23-ter 0�25eg tri tax