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APPLICATION FOR PERMIT ( SAN JOAQUIN LOCAL HEALTH DISTRICT \Q 1601 E. HAZE 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 Health District. Job Address 5530 R. Acampo Rd. city Acampo Lot Size lacre PM Owner's Name Arthur $emalgan Address 5528 Es ACAM-P-0 A Phone Contractor's Name Woods WE:11 Drillingicense No. 282866 Phone 745-2407 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM RFSPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES 100 DISPOSAL FLD. PROP. LINE 5E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I Open Bottom ❑ Manteca Dia. of Well Excavation X14—" " Dia. of Well Casing " 2 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Steell Specifications ❑ Public 1:1 Other El Delta Depth of Grout Seal 50 Type of Grout $S114 & C e]Mt ❑ Irrigation --Approx. Depth ❑ Eastern Surface Surface Seal Installed by Woods Stell Drilling Repair Work Done ❑ Type of Pump SubmersibXe 3hp State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 J fy Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is 4 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �� Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 5 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line rf? LEACHING LINE ❑ No. & Length of lines Total length/size 1'.1 FILTER BED ❑ Distance to nearest: Well Foundation Property Lind.> : T '= -' SEEPAGE PITS ❑ Depth Size Number ,,;:4 n 1 SUMPS ❑ Distance to nearest: Well Foundation Property Linep:'"'h DISPOSAL PONDS ❑ >- '"k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joao4k nty-ordinarS�Ps)"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 fo�is permilN 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." The applicant must call for all requiredinspections. Complete drawing on reverse side. Signed X_ 1.�/ �, _1.. Title: Con tractorDate: 6-4"'86 FOR DEPART ENT USE ONLY Application Accepted by �'�/60 Date Areaad Pit or ut Inspection by `Z'/�� ro _ Date �� final Inspection by & t"`Z Date V 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 AMOUNT REMITTED C RECEIVED BY /DATE PERMIT"N0. Du +EH 13 24(REV.10/831 ®S G7 a7 s a7� `� Iko / _Sq b EH 14.26