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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, 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 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 well/pump and the Rules and Regulations.of the San Joaquin Local Health District. Jab Address 4860_ East Woodbridge Rd City, Acampo Lot Size 4 . 5 acres PM Owner's Name Paul Baumbach Address same Phone 334=4899 Contractor's Name Clark Well License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE5 I$ PieZmeter DISTANCE TO NEAREST: SEPTIC TANK +1_00 SEWER LINES +(46` DISPOSAL FLD. PROP. LINE 10 } FOUNDATION AGRICULTURE WELL OTHER WELL_ 20 ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Attached Design ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n tails ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications yI ❑ Public E) Other ❑ Delta Depth of Grout Seal Type of Grout rV f ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted-if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil Lora depth of 3 feet: Water table depth SEPTIC TANK . / #' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal /� ) Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS E Depth Size Number SUMPS ❑ Distance to nearest: _ Well Foundation Property Line 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, a�d � rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies 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 compensa- tion laws of Califor I ' The applican fo al a ins ctions. Complete drawing on reverse side. Signed Title: VP—Clark Well Date: 14 April 88 FOR DEPARTMENT USE ONLY i (p Application Accepted by b Date Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C7 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE�r -PERMIT'NO. + EH 14-26IREU.10!831 Z %