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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED y , (Complete in Triplicate) �. Application is hereby made to the San Joaquin Local Health District for a permit to construct anWor 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. Lot of Record"' 4865 E. Woodbridge Rd city Acampo Lossie-72 PM . Job Address . Owner's Name George Floyd Address Same Phone 334-5265 Contractor ("1 a Address License No.371 �Ff]_ Phone_ – TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION RIX PUMP INSTALLATIONMR SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 6 S t SEWER LINES DISPOSAL FLD. PROP. LINE+_L5..a' FOUNDATION AGRICULTURE WELL OTHER WELL l- r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing - rt XXIR Domestic/Private 1{))Gravel Pack © Tracy 'type of Casing Steel Specifications #1 0'j- r'] Public L1 Other F1 Delta Depth of Grout Seal 35Q Type of Grout 9 sack I I Irrigation Approxi Depth l I Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump Sub H.P- 2 State Work Done _install Well Destruction ❑ Well Diameter tit' Sealing Material (top 501 De Filler Material (Below 501 rr n TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 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 d PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that i have prepared this application and.t 14ha work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ".41, 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 taws of California." Contractor's hiring or sub-contracting signature certifies ng h?* he performance of the work for which this permit is issued, I shall employ persons subject to workman's compeennsa- tion tavA r � 7__? �The apc I fo respe ions. Complete drawing on reverse sidd. .�–..f Signed Title: VP Clark Well - Date: 1 Nov 1988 FOR DEPARTMENT USE ONLY Application Accepted by �( Date � Area Pit or Grout Inspection by Date �. 3 v U Final Inspection by.. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EI Tracy 835-6385 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 I CK iii RECEIVED BY DATE PERMIT ND. INFO CASH +.EN 1324(REV,t i H 5) EH 14-28