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APPLICATION FOR PERMIT 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 j 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, Joh Address 19690 N Hwy 99 City Acampo Lot Size 40 Acres PM I Newport=. Pacific Capital Properties Carp Phone 714 760 8863. Owner's Name Address eW p Or BeaC 9266 369 San Miguel,Ste 385 ContractorClark Address 2024 E. Charter WaV License NO-3-7-1-5-6-0—Phane2-767 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION RX PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ti ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public F Other ❑ Delta Depth of Grout Seal Type of Grout _. . I Irrigation —..Approx. Depth l 1 Eastern Surface Seal Installed by - 'Q Repair Work Done ❑ Type of Pump H.P. State Work Done " Well Destruction 12C Well Diameter 8.11 Sealing Material (top 501 — 9-5,3�rk Depth 180 Filler Material (Below 501) Same TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) F 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 f SEEPAGE PITS l I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line r- DISPOSAL PONDS ❑ I 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 th_ 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 subj to-workman's-compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: " at in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of Californi The applicantA t for re red ions. omplete drawing on reverse side. Signed Title: VP C1ARK Date:31 Aug 1988 FOR DEPARTMENT USE ONLY a Application Accepted by " /��-- Date Area Pit or rou Inspection by Date Final inspection by Date 4� f Additional Comments: � � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 "Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH qlllu 1 33 a.EH 11241REV.1/85Y -i �V EH 14-28 iff CbL l