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" LICATION FOR PERMIT • JOAQUIN LOCAL HEALTH DISTRICT COPY Y►» � 1 E. HAZELTON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SQ8 (Complete in Triplicate) t and/or all the work hei maden described. This application is c nticomapliance made Sano the Joaquin County Ordinance No.549 r for °permit No. 1862 forcwell//pump atnd the Rules and 1R Regulations of the San Joaquin Local Health District. 2',200 SElft Job Address 4707 Pacific Avenue City Stockton Lot Size Owner's Name ))dotal Corporation Address P.O. Box 5155, San RaTion, CA 94583 Phone (510) 277-2320 Contractor WOOdOrd Drilling Address P.O. Box 336, Rio Vista License No. 581639 Phone 707) 347-4300 NEW WELL al WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: OTHER ❑ �— SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ I I ' DISPOSAL FLO. N/A PROP. LINE —See MP DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES Imo+-a"N/A OTHER WELL See PITS/SUMPS N A FOUNDATION $VP M_FQ AGRICULTURE WELL 2" monitoring well/411 vapor wel TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing 2 & 4 inc INTENDED USE Dia. of Well Excavation Cl Industrial ❑ Open Bottom El Manteca SCh Specifications t Gravel Pack ❑ Tracy Type of Casing i. & ❑ Domestic/Private 201 & 65t Type of Grout ❑ Other Cl Delta Depth of Grout Seal �--� ('1 Public Surface Seal Installed by 4100dUl8T'd Df7111f10 �f7fOanY 1 1 Irrigation 45=85\pprox• Depth I I Eastern H.P.T State Work Done — Type Repair Work Done ❑ yp of Pump Sealing Material (top 50'1 Well Destruction C3 Well Diameter Filler Material (Below 50'1 Depth_— -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I alvaitable'wit hin 20Perm"' f etit'ed if public sewer is Installation will serve: Residence._ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Me Iu11 DL-MDa471 PKG. TREATMENT PLT. ❑ pro art to n 7 ��y Distance to nearest: Well Foundation p y Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property Ina FILTER BED ❑ Distance to nearest: Well SAN JOAQU�tiNTY Number POBLI )01 C11 i'I SEEPAGE PITS I I Depth Siza SUMPS Cl Distance to nearest: Well Foundation prbpe y ine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application 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 Healthes the following Home owner or licensed agent's signature certifies the following. 'I certify that in the performance California." the work t. for which this permit ring or o issued, I signature she not of ation certifies the tollowinn salt certify that n the perfoemancecof to the wok for whichthis permit tis issued,fl shall employ personsrs 1subject[o wotkman!s9ompensa- g:., tion laws of California." The applicant call far all, squired inspections. Complete drawing on reverse side. O� "�✓,r,ln../A�--' Date: / Title:1.��—r---- "-�__-- Signed x FOR DEPARTMENT USE ONLY Date 2— Area Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: p Manteca 823-7104 ❑ Tracy 835-638.5 ,.91 ❑ Sic 466-6781 ❑ Lodi 369-362195201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA CK a C VED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED n14- EM CAASSH,�(( �^ h ('I,NFO /y�}/�! G/�� ^'l,'l`r . EH 13-24 IREV.I/w5I INVI V , 'V✓ 0gty EH 14-26