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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone Q091 466-6781 PERMIT EXPIRES TYEAR 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.b49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 8629 SchmielY dt Road Cit Acampo Lot sae PM Owner's Name Bob Bradshaw; .r-.' • Address.;:`same as above Phone GOEHRTNG -PUMP BoX 113 727--5548 Contractor Address Loekeford, C;:3 , __- License Phone -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES DISPOSAL FLD. " PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..:_ �.�a✓-�-,�.:..�.-a.::.-.mss. _�;.,;�..,..�1 ._s...--,�. .,:.. �,.-.� .s,.�.-:-�-,�=,.=-„r__.�s4-`-�-�--{ r.=-�a,.�.--:.« M � _- � 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' Cl Tracy Type of Casing Specifications 1-1 Public ❑ Other s ?” C1 Delta Depth of Grout Seal Type of Grout 1 i Irrigation .�-Approx. Depth,�I I,Eastarn Surface Seal Installed by i Repair Work Done Ul Type of Pump -i 4 H.P. State-Work-Done--- Well Done_--- Well Destruction i Well Diameter 8a Sealing Material (top 50'1 concrete Or grout d Depth 1 70# ' Filler Material (Below 50'1 pea r6Ck Or Sande "r TYPE OF SEPTIC WORK: NEW INSTALLATION I I .REPA4R4ADDITION-t-1---DESTRUCTION l is (No septic system permitted if public sewer is I 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 ❑ Type7fsAfg"" --- - Capacity"- No. Compartments } 1 1Yi';w' .r PKG. TREATMENT PLT. ❑; amu, Method of Disposal 3`Distance�to-nearest:, r' Well.-77 Foundation Property Line LEACHING LINE ❑ No. & Length of lines` } Total length,/size FILTER BED ❑` Distance tto nearest: Well Foundation Property Line 3 SEEPAGE PITS I I Depth I Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl x I hereby certify that I have prepared this applicatidn and that the work will be done in accordance with San Joaquin county'ordiriances, 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 h manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follo 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 C f r ' ' llnA _ 3 The applican. all f 11 required inspections. Complete drawing on reverse-side., i sr ;. . . Signed - S _- ---.Title:"� _� :-Bkpt ' Date: 08/.1.987 FOR DEPARTMENT USE ONLY r Application Accepted by Date /9Area ybfPit or Grout Inspection by bate Final Inspection by Date 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 CK 0 RECEIVED BY DATE /PyEERMITT''NO. + EEH H 13-241REV.I/H51 /_/ /1L/XT