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tr" r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZED ON AVE., STOCKTON, CA <br /> Telephons 11209! 466-6781PERMIT EXPIRES YEAR FRtvinti DATE ISSUED <br /> (Complete in Triplicate) <br /> Appliratia^.is ht"o y made to the Sari Joaquin Loral Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 fof sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f <br /> Job Address 19690 North HWY 99 city Acampo Lot sire 4 0 Acres pM .. <br /> Newport Paci fc Capital Properties Corp. 369 San Miguel, Ste 385 <br /> Owners Name Address P.;r•:,;'"`or E6-aa 'A r phone 71 C <br /> Clark Well & Equ meet Co., nc�Cha�rter 92560 <br /> Contractor rest License No.?'L q 5SZ Pharre " <br /> TYPE OF WELLIPUMP: - NEVti WELL Cl WELL,REPLACEMENT e5X DESTRUCTION'S <br /> PUMP INSTALUATIONIU SYSTEM REPAIR 0 OTHER El k <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES 25 1 DISPOSAL FLD.__2.QQt PROP. LINE1_CO <br /> FOUNDAIIGN AGRICULTURE WELL OTHER <br /> WELL__!0, PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiF7�s <br /> D Intfustriai 0 Open Bottom 0 Martteea ilia.of Well Excavation Dia.of YJen Cas .10 3/Al <br /> O Domestic/Private XXGravei Pack 0 Tracy Type of Casing S eel _ Specifications .188 <br /> 12 Public n Other n Delta Death of Grout Seal 200 Type of Grout 9 Sack <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done JIM Type of PumSuH.P. � i <br /> V State Work Gone tis a 6l I <br /> 4 <br /> Well Destruction Yff Well Diameter 8" Sealing Material(top 501 9 Sack <br /> Depth 219' Filler Material(Below 5D) Sac <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1 DESTRUCTION i I (No septic system permitted if public sewer is f <br /> available within-To feet,I . <br /> I} Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: "- Water table depth •r <br /> SEPTIC TANK u -IMMIMfg Capacity Pio. Compartmona ' <br /> PKG.TREATMENT PLT.OMethod of Disposal <br /> Distance to nearest; Weil Foundation Property Line— <br /> LEACHINVss LINE 0 No.$Length of tines Total length/w 1 <br /> FILTER BED 0 Distance to nearest: Wdl Foundation Property Line <br /> SEEPAGE PITS t I ,Depth Size Number <br /> SUMPS 0 I0rstancs to nearest: vveuI.OUnOSIM Property LMS <br /> DISPOSAL PONDS C7 <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with Sari Joaquin cbunty ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health Dri-strict. <br /> Horns owner or licensed agerWa signature certifies the following:"I certify that in tate performance of the work for which this permit is issued,I shaft not <br /> employ any person In such manner as to become subject to workman's cornperr^,ation laws of California."Contractor's hiring or sub•contractimg signature <br /> certifies the fatlaw(ng:"I co that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa- <br /> tion laws of Calif . 41 If <br /> -Me applicant i ar al�+r ed ns, ompWa dr-w'.ro on reverse side. f <br /> 5. VP Clark Well 17 Aug 1988 <br /> Signed Title: L7ate: <br /> FDR DEPARTMENT USE ONLY <br /> Application Accepted by hate <br /> Pit or Grout Inspection by Date Final Inspection by ,�. Gate <br /> Additional Comments: <br /> 0 stk 4094WI 0 Lodi 3G9-3&21 O Mvntocs SZ3-7104 Q Tracy M.6385 � <br /> Applicata-Retum all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Boz 2004, Stk_, CA 95201 V <br /> y <br /> 1AMOUNT DUE AMOUNTFIFMIITTED 1` K RECEIVED By- /DATE PE"MIT'Ko. <br /> ZED I CASH <br /> ..LM Y.id4 tgEV.I/�51} 1l rl � �/� jSA.r L�JL ! / � �����7� • <br /> EM 1628 +'�rJJ - •r <br />