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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 4865 East Woodbridge Road Acampo 20 Acres , Job Address City Lot Size PM George Floyd same 334--5265 Owner's Name Address Phone Contractor Clark Well Address 2024 East Charter License No.371560 Phone 462-7676 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION N PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FL[310 o,_ PROP. LINE 0— t 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout _I I Irrigation - _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. Statt:h ork Done_ Well Destruction �71 Well Diarrt r Sealing Material (top 50') y Sac Depth xx�� 2t3 Filler Material (Below 501 9 sack TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) 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 SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: " that in the perform ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif is ' The applicant s 1 0 1 quir i s do . Complete drawing on reverse side. Signed x rtle: VP Clark Well Date. 29 Sept 88 FOR DEPARTMENT USE ONLY `l - Application Accepted by T CT7C57� Date Area Die! Pit or Grout Inspection by r� Date Final Inspection by Date Additional Comments: _ F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-&WS 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 CASH CK 6 RECEIVED BY D,gATE�j PEERM17'NO.. +.EH 1 -241REV-ii+51 —2� EH 144-26