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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. FIAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. + 4-578 mast ^food' ridge AcomBo �.eoJI(2."' Job Address City Lot Size PMS_ Archie Baumbach 4678 East Woodbridge Phone 209-334-3188 Owner's Name Address . :5OX 1 Contractor North Valley BrillIii ;�nc . Gorning, ,�0alii .�irl-67�� 4188x4 Phone^916-82�-01 2 TYPE OF WELL/PUMP: NEW WELL CX WELIL REPLACEMENT [I DESTRUCTION O. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' OTHER ❑ . —DISTANCE TO NEAREST;-SEPTIC TANK- 100'.. .SEWER_LINES- DISPOSAL FLD.5 U _PROP. LINE FOUNDATION" AGRICULTURE WELL - OTHER WELL � PITS/SUMP$- INTENDED USE TYPE OF WELL PROBLEM AREA, CON'STRUCT'ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5 8 `1 10 ga "stemel Specifications XC Domestic/Private 9 Gravel Pack ❑ Tracy Type of Casing: p F-1 Public a Cl Other ❑ Delta Depth of,Grouf Seal � �QO f • ' �_ Type of Grob( neat CETTlE I 1 Irrigation 40&1 -Approxi Depth 11 Eastern Surface Seal Installed by sand 50 1 t _ r Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction 01 Well Diameter Sealing Material (top 501 ---- °�' Depth I Filler Material (Below 501F- t r TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION I I- ..DESTRUCTION I I INo septic system permitted if public sewer is k available-within 200 feet. , a ° Installation will serve: Residence Commercial_ Other y );.3! Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: *: r Water table`depth ° SEPTIC TANK ❑ Type/Mfg Capacity a No..Compartments f -PKG. TREATMENT PLT. ❑ Method of Disposal. C`. f Distance to nearest: VVell Foundation Property Line i LEACHING LINE Cl No. & Length of lines Total length/size i F FILTER BED ❑ Distance{to nearest: Well Foundation � Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation f Property Line ° r DISPOSAL PONDS ❑ I 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 I rules and regulations of the San Joaquin Local Health Di§trict. 'E 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." Contractors hiring or sub-contracting signature -.certifies the following:"I certify that in the performance of tFie work for which this permit is issued; I shall employ persons subject to workman's compensa- e tion laws of California." The applica a�mu4t call for all requ spections. Complete drawing everse side. Title: Dat Signed e:E FOR DEPARTMENT USE ONLY �j ,(� Application Accepted by Date ! ,3 ��u Area o Pit or Grout Inspection Date Final Inspection by Date/ Additional Comments: Alf t`7 'e' "" 6-e a zZ GU r S t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEC INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f C�c7 2S`1Z C!-mac rEH 13-24(REV.iia5) EH 14-26