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SCMNED APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tComplete in Triplicate) l 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. 4851 East Woodbridge City Acompo Lot Size Z '44�yNS PM ' Joh Address Owner's Name Address -- Bob Bieffel 4851 East Woodbridge Phone209- 69-1819 P.O. Box 108 Contr*actor North Valley Drill,4g, In.0 . Corning, Cali.fLicense No. �a 7 88 -�.,__Phone 9 1 '2 TYPE OF WELL/PUMP: NEW WELL it WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLAII ' � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ sly SEWER LINES DISPOSAL FL PROP. LINE FOUNDATION r - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M Domestic/Private J� Gravel Pack ❑ Tracy Type of Casing 10ga S to el Specifications M PublicO CltOther n Delta Depth of Grout Seal 3001 Type of Grout nPa. t CPTtI(� t I I Irrigation U—.,Approx. Depth I I Eastern Surface Seal Installed by sand seal _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living 6nits: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ s t' Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property-Ane. SEEPAGE PITS l I Depth Size -_ -____ __ _ __ __ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k 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 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 tlis permit is issued, I shall not 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." The applica must call for all required ins ns. Complete drawing on reverse side. Signed X Title: f �t� L2---7 Date: FOR DEPARTMENT USE ONLY 9 C1 Application Accepted by Date + ' Area Q Pit or Grout Inspection 'f a r Date rJ 5 inal Inspection by Date Additional Comments: v Z Gr u �� Gv Ch Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63B Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CLASH �y {yC, +.EH 13'241REV.t/K5) �o 7�7-Z_ �-30 -?,FCF EH 14-2e