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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZETON 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. 24475 N. Watkinson Acampo 6601 x 330' 5 acres Job Address City Lot Size PM Owner's Name Bary Memory Address 2056 Sonoma phone 943-5633 Clark Well & Equipment 371560 462-7676 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL K' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ) SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 200 1 SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL "i"100 PITS/SUMPS _ j INTENDED USE TYPE OF WELL PRpBLEM AREA CONSTRUCTION SPECIFIC�1Zl0IS/„tt 14 ❑ Industrial Q Open Bottom 1:1 Manteca Dia. of Well ExcavvaSion Dia. of Well Casi g /� x❑ Domestic/Private E) Gravel Pack ❑ Tracy Type of Casing tree Specifications k �/� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 0 1 Type of Grout 0 sank. ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump sub H.P. State Work Done installj Well Destruction ❑ Well Diameter Sealing Material (top 501 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is (N 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 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 ❑ ,.Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 District. Home owner or licensed agent' a 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 m er as to a subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signature certifies the following: "I ce hat in the nce of a work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca, r 'a The applican tt. . r re d " spe C late awing on reverse side. r Signed X Title: VP—Clark Well Data: 17 Aug 1.987 FOR DEPARTMENT USE ONLY Application Accepted by J Date l Area Pit or Grout Inspection by XA Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE (NFD AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV. 10/83M EH 1 / - ✓Q _ ` 425 47/4015/ ��