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APPLICATION. FOR PERMIT i-) � � �' ''� �„� SAN JOAQUi"! LOCAL HEALTH DIS 1601 E. HAZELTON AVE., STOCKTON, CA APR 16 W PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE IS ;;.� � L (Complete in Triplicate) i. �•a- 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 4579 E. Acampo Rd. IA&M Ma�-u rvi)ion Name Owner's Name Acampo Communi ty PUmpAddress 4579 E. Acampo Rd. Phone Contractor's Name G oehri n Pump License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U 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 1_ Industrial U Open Bottom Manteca Dia. of Well Excavation L( Domestic/Private F-1 Gravel Pack ❑Tracy Dia. of Well Casing 17 Public F-1 Other Delta Type of Casing ' V Irrigation Approx. Eastern Specifications Cathodic Protection Depth ❑ roDepth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done EJ Type of Pump Sub. H.P. 5 State Work Done Removed 7HP & replaced W Well Destruction U Well Diameter . Sealing Material (top 50') 5 .HP Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a.depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ej Depth Size Number SUMPS El 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, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed 4,gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I not employ any person in such manner as to become subjecttoworkmanis compensation laws of California." Contractor's hir' r sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is I all employ persons subject to workman's compensation laws of California." The applicant r//a�ll re ired inspections. Complete drawing on reverse side. Signed X / 71J Title: Bkpr. Date: 4/13/84 d / R EPART IT JSE LY Application Accepted by 0/✓ `� Ir'ea 0� Stk 466-6781 Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date _ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO T --- -- chi-- — — i 10/82 500 EH 13-24 REV. 10/82 14-26