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Newpc APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. ----- 19690 North Hwy 99 CitvAcampo Lot Size 40 Acres PM rt Pacific Capital Properties Corp. 369 San Miguel, Ste 385 Owner's Name Address Newport Beach CA Phone 714 -.7 — DATE PERMIT' N0. 2024 E. Charter 92660 Clark Well & Equ gess CO. , Inc. Contractor License No. 3:71 560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT PSX DESTRUCTION'ME . PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES 25 t DISPOSAL FLD. 200 t PFOP. LINE1 0 r FOUNDAI:rt3N AGRICULTURE WELL OTHER WELL—i-0-r_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF1CA_411ONS tt 10 3/ 4 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Steel 1 88 ❑ Domestic/ Private XXGravel Pack ❑ Tracy Type of Casing Specifications ' Public (_1 Other ❑ Delta Depth of Grout Seal 200 Type of Grout 9 Sack I I Irrigation —. -Approx. Depth I 1 Eastern Surface Seal Installed by Clark Repair Work Done XX Type of Pump Sub H P 30 State Work Done Install Well Destruction Yf�X Well Diameter 811 Sealing Material Itop 501 9 Sack 21 T- 9Sack Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.l 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. ❑ M� 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 Number SUMPS Ll Distance to nearest: Well Foundation Property Line 2 DISPOSAL PONDS EI ��-` 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." Contractors hiring or sub -contracting signature certifies the following: "I certifythat in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Calif nia. The applicant I or a re ed c ' ns. Complete drawing on reverse side. VP Clark Well 17 Aug 1988 Signed X Title: Date: FOR DEPARTMENT USE ONLY �f Application Accepted by Date [ _ W Area i Pit or Grout Inspection by Data Final Inspection by Date J� Additional Comments: ❑ Silk 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 +. EH 13-24 (REV. J)n5 EH 14-26 FEE INFO DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' N0. jAMOUNT