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I APPLICATION FOR PERMIT C SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Healih District. E Job Address22221 N. Bender Rd./7.00 W. Peltier city -- AcampQ - Lot Size PM Owner's Name Stuart Bewley _ Address 2119 W. 'March Lanes STEN Phone 95-7-6666 Contractor PUryiance Driller)&resTne. P. 0. Box 64aLintdease No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT=D DESTRUCTION ❑ PUMP INSTALLATION M SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 809 Dia. of Well Casing 8 8 X Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications I"1 Public n Other 6l,"Delta - r Depth of Grout Seal 50 Q Type of Grout Cent _ I 1 Irrigation " ' - QRpprox"Depth-`' I I'Eastern H Surface Se it Installed by y Repair Work Done 11 Type of Pump SL1bmer. H.P. 15hp tiStaia Work Done drill new, well -instalY Well Destruction ❑ Well Diameter Sealing Material Itop 50') x5. xiew PUMP Depth Filler Material (Below 50') �1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 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 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 l I Depth Size r Number SUMPS 0 Distance to nearest: Well Foundation Property Line i 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 " 1 j The plicant st all for required inspections. Complete drawing on reverse side. c Signed .� Title: Corp. Secretary Date: 4/29/88 _ OR DEPARTMENT USE ONLY Application Accepted by Date Area I[ Pit or Grout Inspection by Date Final Inspection by 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 Ay MOUNT /REMITTED CK 4 CASH RE/CEIIV�ED BY DATE PERMIT"NO. + 10C I EEH 13-24 H 14-2t1IREV.tiK51 �� r� JJy��tJ0 lo� / // s� a p 12t I T�' Vl� O