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t ' ,r APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 'I'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. Job Address 4980 E. Woodbridge Rd. City Acampo Lot size PM - Owner's Name Marvin Mayer Address 4980 E. Woodbridge Rd. Phone 17754 N. Hwy, 88 Contractor Goehrin q Pump Address License No. 309031 Phone_ 7-5548 TYPE OF WECL:PUMP: ',NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER M: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public I] Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation-. - --Approx. Depth l I Eastern —Surface Seal Installed 6y �� d Ll Repair Wotk"Done O-_--7ype-of-Pump- State-Work,Done,_ An -rep iced p mp Well Destruction ❑ Well Diameter Sealing Material (topt50 1. Depth = Filler Mat+arial (Below 50')! TYPE OF SEPTIC WORK: NEW-INSTALLATION I.i`,REPAIR/ADDITION LI DESTRUCTION I I iNo septic system permitted if public sewer is f s available within 200 feet.) 4Yi _ •�,.. r Installation will serve: Residence— Commercial Other t' Number of living units: 1 Nurnber'of bedrooms •t Character of soil to a depth of:3 feet_. , j Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ iMethod c� of Disposal osal Distance to nearest: Well i Foundatlo' _ Property Line i :J. E LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 1 Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS- Q — 7 _ . - . - — I hereby certify that l 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 Health District. Home owner or licensed a nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in s nnar as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow• I rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- '� tion-taws of Cali r I s j j �;,,``±±. yr ,,j [� *� y jos The applicant f r required inspections. Complete drawing on reverse side. Signed X Title: Bk10r• Date: 09/1.5/87 FOR DEPARTMENT USE ONLY /1 f Application Accepted by Date �' r Area v Pit or Grout Inspection by Date Final Inspection by 6L 4!4rDate l� Additional Comments.- 0 omments:❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 p Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO /) CASH + EH13-24(REV.t i y 51 3� f - EH 14.28