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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AINN 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 `� ►� C PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Vs (Complete in Triplicate) ti �� ;` ✓r' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein-dbsed.`This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules�*Iations of the San Joaquin Local Health District. Job Address 8534 E. Acampo Road _ city Acampo Lot Size PM Owner's Name LAURENCE CALLOWAY Address 8534 E. Acarap1p Phone Contractor GOEHRING PUMP Address 17754 N. Ulff, 88 License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X 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 Ll Other Cl Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth 1 I Eastern -r Surface Seal Installed by _ Repair Work Done '( Type of Pump -);,k / = H.P�t i s9 .i State Work Donee I I hand d»cr we 11 Well Destruction ❑ Well Diameter Sealing Material Atop 501 Depth Filler.Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RLPAIR/ADDITION I I DESTRUCTION l 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 FILTER BED ❑ Distance to nearest: Well— Foundation Property Line t SEEPAGE PITS I I 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 liceCrtify ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fo11 withe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor The applicant m td inspections. Complete drawing on raveSigned Xell, Title: r, Date: / FOR DEPARTMENT USE ONLY �_ a Application Accepted byDate < �Area Pit,or Grout tIInspection b11 - y f / Da. Final Inspection by Date N_ Additional Comments: AIS �1 "} , r't. �' i;.f'�_� I'' /:q",�(:X fi �.. {� t, /i � , ❑ Stk 466-6781 ❑ Lodi 369-3621 .,- ❑ Mantecle 823-710 ❑ Tmcy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. EH 13-24 EH 14-28(REV.I/H 51 ,�