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Iwo <br /> }iT•yJ' <br /> 3 APPLICATION FOR PERMIT ., <br /> SARI JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. tiAZE,i ON AVE., STOCKTON, CA <br /> Telephor$ (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAH FF.oLq DATE IScOE0 <br /> (Complete in Tripiicate) <br /> Application is nsteby made to tie San JcaRL`.n Local Health District for a permit to construct and/or install the work herein dMebed:Th+S application is <br /> made in carnpiiance with San Joaquin County OTdhaneo No.549 for sewage or No.1862 for welt/pump and the Rules and Regulations Of Lite San Joaquin <br /> Local Hoalth District. : <br /> 19690 N Hwy 99 City Acampo Lot Size 40 Acres— PM l <br /> Jots Address <br /> Newport Pacific Capital Properties Carp ,,, 714 760 886 <br /> Owner's Name Andress an ].t lle r Ste 385 ewpC+r eac 2 6 <br /> ContractorCzark Address 2024 E. Charter Wa License Ivo'4'71 560 Phone - <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION RX { <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTii u t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PRO aLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> 0 Industrial 0 Open Bottom ❑Manteca Dia.of Well Excavation Dia.of Wep Casing e <br /> 0 Domestic/Private 0 Gravel Pack ❑Tracy Type of Casi Specifications -43 <br /> I•'l Pub!iL 171 Other M Delta Depth of Grout Seat Type of Grout <br /> I 1 Irrigation —Approx. Depth I I Eastern Surface Seal lnstatied by --- -iQ <br /> Repair Work Done' D Type Of Puimp H.P. State Work Done <br /> Well Destruction EY Well Diameter 's._ Sealing Material (top 54') _—�Sa,�1r - <br /> Depth. 1 Finer Material fselow 5trl same <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRlADDITtON I 1 DESTRUCTION [ I (No septic system permitted if public sewer is <br /> avaita$le wiinin 200 fi{ri.i � F <br /> installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of snit to a depth of 3 Leet: Water table depth <br /> SEPTIC TANK 0 Type/Ivifg Capacity nip.CvmpS,cir,8r�i: <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE Ol No.&Length of lines Total ienginisixe <br /> FILTER BED © Distance to nearest: Wen Foundation PropeRy Line <br /> 3 <br /> SEEPAGE PITS . 1 1 Depth size Number r <br /> SUMPS ['i Distance to nearest: i(yeii 'rounda2ion Property i.ira - • <br /> r• <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin courrty ordinances,stela laws, and <br /> rules and regulations of the San Joaquin Local Health Des n' <br /> Home owneT or licensed aipra's signature certifies the tollowing.,'I certify that in the performance of the work for vohich this permit is issued.I shall not <br /> employ any person in such manner as to become sub ,workman's-compensatkm lows of California."ContraotoPs hiring or sub-contracting signature <br /> certifies the loRowirng:" at in the performance of the work for which this permit is issued,f shall employ persons subject to workman s compenss, <br /> tion taws of Californ' / <br /> Thv appSit�ttRs •fkx r r ed - jerts ,�.'sfv drawing an reverse silo. <br /> i�/�j� 'rice: VP CIARK <br /> FOR DEPARTMENT USE ONLY <br /> ' fApplication Accepted!3y irate Area <br /> ! ZA r��� ♦fir._ 1 _ /fri <br /> Pit or tri nspection by �,.. Date�� � Finai Inspecs:Pn by Date b <br /> r Additional Comments: �T.flY59 I �► 1� fO <br /> © Stk 46&M1 © Lodi 369-3621 ❑h amore A23�7104 0 Tracy 1 -6M <br /> Appficant. Retum all copies to:Environmental Health Permit/Services 1501 E.Hazelton Ave., P.O. Box ZW,Stk.,CA 55201 <br /> „fE AMOUNT DUE i1 (AMOUNT REMITTEDCASHRECEIVL:D BY DATEE/�( PERMI7,NO. <br /> INFO*-EH 1324 tR*V.'v»S3 i <br /> EH 14-M 1f - <br /> f <br />