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A 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. Job Address 5530 B. ACatmpo Rd. City Aca►po Lot Size laCre _ PM_ Owner's Name ArthUr KMalYa n Address 552+8 Bt ACampo Me Phone Contractor's Name Woods Well Drillin cense No. 282866 Phone 745-•2407 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM RVAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES 100 DISPOSAL FLD. PROP. LINE 50 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial * Open Bottom ❑ Manteca Dia. of Well Excavation 14"V ?.___ Dia. of Well Casing tt 2 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 Type of Grout Sand & cen ent ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 10ods Well Drilling Repair Work Done ❑ Type of Pump SubmersilPX.e 3ho State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ,h Depth Filler Material (Below 501 ti TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other C^ Number of living units: Number of bedrooms r Character of soil to-a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well Foundation Property Line r=* LEACHING LINE © No. & Length of lines Tota! length/size `-- '`' -� ' IND 1i FILTER BED ❑ Distance to nearest: Well Foundation Property Line ti , ,_ ., `w SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Liner DISPOSAL PONDS ❑ ` �' u- � hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin'county ordinari4e)3state 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'`41s;permitis 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 California." The applicant must call 'for /all requir inspections. Complete drawing on reverse side. Signed X �leLf �� _ Title: Contractor Date: 6-4-86 FOR DEPART ENT USE ONLY Application Accepted by �N Date�1 Area O/ Pit or rout Inspection by� "pl1 v �;�' Date �� final Inspection by `4� ��`�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFOt. C + EH 13-24(REV.10183) ),s ^- �` -sq EH 1426