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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> • <br /> Application is hereby made to the Son Joaquin Local Health District for a P•fm to cors mifor v and/or <br /> i and the W R.pt�latiats o♦cite <br /> I ods n rt <br /> cotpti —with San Joaquin County Ordinance No.5"for f+ ,eW <br /> Of No,ISM Son Joeq <br /> Loc*Health District. <br /> 28000 Sowles Rd* AcampofiCa. _ city. Acampo Lot Sin 40 ac PM <br /> Joe Andress - <br /> Roy Ramaceiotti g ddrs16 P.O. Bx 661 Pioneer,Ca. Phoma 209 295-46 <br /> Norm Owner's Noae 2 <br /> Contract <br /> -lioods Well Drilling,dfe..11944 Simmerhorn RdeLKense No. 282866 Phone 745-2407 <br /> TYPE OF WELL/PUMP: NEW WELL3u WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTAL LATIDf i SYSTfJi1 1 ❑VEPAIR C1 JF 50 t <br /> DISTANCE TO NEAREST: SEPTIC TANK j1�3111J SEWER LINES 11�V DISPOSAL FLD. 1J PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE`1F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 811 <br /> Lcht0ust*i* (7Cppen BoR�..ii Cl Mantacs Dia.of Well Excavation Bot Dia. of Wen Caning <br /> Type of Coning Steel 126a•1601 <br /> port+satic!Private ❑ Gravel Pack C Tracy <br /> E, t7 Delta Depth of Grout Sesl 50,t ro <br /> Type of Gut s and & ei <br /> Irrigation 250 a. Depth - Eastern Surface Seal Installed by <br /> Woods <br /> Repaw Work Done x Type of Pump SIM. H.P. 3 State Work Done Z1eW <br /> Weal Destruction _. Wen Diameter —_ Sealing Material Itop 50'1 <br /> Depth Filler Material 186100 50 1 C <br /> TYPE OF SEPTIC WOPK: NEW INSTALLATION C. REPAIR/ADDITION [1 DESTRUCTION L� (No septic system par netted if public sewer b <br /> available within 20D feet.) C <br /> Installation will serve: Residence _ Commercial _— Other -- <br /> Nurnber of living units: - — Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet <br /> SEPTIC TANK Type/Mfg ----. _ Capacity_- No. Compartments C <br /> PKG TREATMENT PLT Method of Disposal <br /> Distance to nearest Well_ Foundation — Property Line <br /> R <br /> LEACHING LINE No. 6 Length of lines — Tot*length/si" ` <br /> FILTER BED nistance to nearest: Wen Foundation Property Line <br /> SEEPAGE PITS Depth —Sir NunWer -- <br /> SUMPS Distance to nearest W.' --_.___— Foundation Property Line <br /> DISPOSAL PONOS i <br /> I hereby certify that I have prepared this apph soon and that the work will be done in accordance with San Joaquin county ordinances. state lays,and <br /> rules and reputations of the San Joaquin Loc*Health District. <br /> Noe owner or licensed agent's rupnatu"I certifies the following: "I certify that in the performance of the work for which this permit is issued.I and not <br /> Horne <br /> employ any person in such manner as to become subject to workman(s compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following'"1 certify that n the parfomance of the work for which this permit is issued.1 shag emPloY pens subiW to workmsri s compsnss- <br /> tion laws of Calfomie•• <br /> The stunt rust CAN for ON raQuked irMKtkA Coniplrits drawing on revere 1106. <br /> rOnto: �4f� <br /> Spred X .-._-��=—� ----- Tit1s: _QWnSS <br /> ,, frOlE 189 <br /> DEPARTMENT USE ONLY f <br /> AMW_st,on Accepted by / <br /> IL <br /> ---=Dalt Final fnep•c ^by <br /> PO or Grout Inspection by — <br /> Additional COO nnienIS' -- —--- -- <br /> Stk 466-"1 1' Lodi 3W301 Mani 60-7104 ) Tracy 835-6:145 / <br /> Apphcant Renin N copies to: EnvirorrriwK*Heehh Pernwt/Services IGO', Eehon. HarAve.. P.O. Bos 2008, Sok.. CA !6201 <br /> fEE AMOVNt <br /> �AlM(TTEO USN RfcvrW0 ey DATE PERM(? NO <br /> 'r �,�/'� % ,1-�C_�'.� <br />