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APPLICATION FOR PERMIT SRN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 Joaau� Lo_c�l_Fjeaa�- Di rict. Job Address 4579 E . Acampo Rd. l f�bcM M Slubdiv Sion Name Owner's NameACampo Community PUM Address 4579 E. ACampo Rd. Phone Contractor's NameGo ehr lnq Pump License No. 309031 Phone �- TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ,_J SYSTEM REPAIR j$ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom []Manteca Dia. of Well Excavation---- Domestic/Private xcavation- -Domestic/Private 7 Gravel Pack ❑ Tracy Dia. of Well Casing 1] Public f-1 Other D Delta Type of Casing Lj Irrigation Approx. E] Eastern Depth Specifications F—ICathodic Protection p Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump ,Sub H.P. 5 State Work Done Install sand separator Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION E) (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. E] 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 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, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is iss*Ishalnot employ any person in such manner as to become subject to workman§ compensation laws of California." Contractor's b-contracting signature certifies the following: "I certify that in the performance of the work for which this permit ish 11 employ persons subject to workman's nsation laws of California." The applicant all r quired inspections. Completed win on everse side.Signed X Title: Date: FOR DEPARTMENT USE ONLY a Stk 466-6781 Application Accepted by �_�Cn CSL Area _ Additional Comments: N Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by o— Date i Tracy 835-6385 Applicant - Return all copi s to: Environmen 1 Health Permit/Services 1601 E. Hazelton*e., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �� AOL e EH 13-24 REV. 10/82 10/82 500 14-26