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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 rt 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 8775 Fact Acam o Rd City Acam Q Lot Size 1 8 Acrca PM Owner's Name Marvin Stirm Address 1 408 Vin Rose Lodi Phone 334-0946 Contractor Clark Well Address 2024 E. Charter StknLicense No.371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL = WELL REPLACEMENT ❑ DESTRUCTION [I PUMP INSTALLATION 1X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 _ SEWER LINES DISPOSAL FLD. PROP. LINE 9V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 11 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 911 Dia. of Well Casing n >kDomestic/Private lij Gravel Pack ❑ Tracy Type of Casing PVC Specifications 160 F] Public Cl Other ❑ Delta Depth of Grout Seal 100 r Type of Grout 9 Sack I I Irrigation —_ Approx. Depth I I Eastern Surface Seal Installed by Clark _ v Repair Work Done ❑ Type of Pump Suh H.P. 2 State Work Done install 147 ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') --- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 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 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 SEEPAGE PITS I I Depth Size _ Number SUMPS 11 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 Calif n'a.' The applicant c fo all qu d in do . Com I to drawing on reverse side. Signed X Title:VP—C1 ark WPI 1 Date: 4 Jun 90 F NT USE ONLY Application Accepted by Date C� -�--� t/ Area 1 Pit or roy� Inspection by g,"Date Z—� ,Og�717 Ainal Inspection by 04 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 A OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH13-24(REV.I/H 5) 7 `J•�