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APPLICATION FOR PERMIT r � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I 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.599 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Parcel 25 &48 ":"Corner of . } `r Job Address City Acampo . Lot Size. 24 acresWoodbridge PM Owner's Name LT ami n a T n y p S t m e Tri t s— Address Phone c/o Hose , Fenton , Jones, &,,App e1"-- iric:` "San Jose , CA 95113-2396 Coritractor mss 2826 E. M rtle St . LicenseNo. 51 2268 Phone 465-'8712 TYPE OF WELL/PUMP: NEW WELL ❑ RE CE DESTRUCTION 011 shallow bort gs I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IK12 to 10 feet d e p DISTANCE TO NEAREST: SEPTIC TANK N,4n SEWER LINES DISPOSAL FLD.N/A PROP. LINE FOUNDATION _N_� AGRICULTURE WELL :NZA_ OTHER WELL=IV,A PITS/SUMPS i INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Fr— Dia. of Well Casing N/A ❑ Domestic/Private ❑ Gravel Pack E. Tracy Type of Casing N/A Specifications i' ❑ Public X OtherS011 ❑ Delta Depth of Grout Seal 1-7 fet eType of Grout ' F1Irrigation 2-L0_%0 rrdMtg ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter b iNC, Sealing Material Itop 50') Sam Depth '&4ly - 10-1�:k Filler Material (Below 50') y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 l .. PKG. TREATMENT PLT. F7 Method of Disposal N _ 4 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 ❑ Depth Size Number SUMPS O Distance to nearest:.-. 'Well Foundation Property Line DISPOSAL PONDS ❑ Rr hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and11 -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 noel A 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." -- s The applicant !call for all required inspections. Complete drawing on reverse side. t2 A Signed Title: Date: �} F PART SE ONLY Application Accepted by Date z" qr Pit or Grout Inspection by Date Final Inspection Die Additional Comments: ❑ Stk 46&-6781 ❑ Lodi 369-3621 E3 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 n r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.