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APPLICATION FOR PERMIT 1 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 8534 E. ACAMPO ROAD City ACAMPO Lot Size PM Owner's Name DAVID SIMMS Address 8534 E. ACAMPO ROAD, ACAMPO Phone 334-1048 Contractor NOACK PUMP COMPANY Address 4500 E. FREMONT ST, STOCLKTA No. 504513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1XX SYSTEM REPAIR ❑ OTHER ❑ 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 F1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth 1 1 Eastern Surface Seal Installed by - Repair Work Done X[XI Type of Pump CIIRMERS1BLEi.P. 3HP State Work Done pry Well Destruction ❑ Well Diameter Sealing Material (top 501 PIIMP & RFPI ACFI1 WITH `(/\ Depth Filler Material (Below 501 66MFCTTC SUR PIIMP TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPA1t+4ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial__ Other _ 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L1 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 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 ca II required inspections. Complete drawing on reverse side. Signed x DICK TAYOW G Title: SALES & SERVICE Date: FOR DEPARTMENT USE ONLY Application Accepted byc Date f `� Area / j Pit or Grout Inspection by Data Final Inspection by e*�*/r Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PER 'NO � (//t + EH 1 -24 IREV.I/K5) EH 144-28 43S -- �/ S l �u�L{A- 2S 1 "elc7