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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. 4920 East Woodbridge Road. Acampo 20 acres Job Address City Lot Size PM Owner's Name Marvin Mayer Address same Phone 369 0577 Clark Well 2024 East Charter 371.560 462-7676 Contractor Address License No, Phone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ �� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL D PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL.57' PITSISUMPS 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 M Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ r I i Irrigation _."Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter SG�tr Sealing Material [top 501 9 sack Depth 75Filler Material I8elow 501 9 sack �a TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) r,(,) I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feeC 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 I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di3trict. 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." Contractor's hiring or sub-contracting signature certifies the following: "I if 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 Califo ia.' The applicant 1.t ca all ed i ctions. Complete drawing on revers side. - VP-Clark 29 Sept 1988. Signed X Title: Date: 5 FOR DEPARTMENT USE ONLY 1 Ii Application Accepted by Date Area ? Pit or Grout Inspection by Data Final Inspection by A, Date '� b 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 CASH R CEIVED BY DATE PERMIT'NO. y +.EH 13-241REV.1/n5l EH 14"26 G J17.J