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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Lot of Record Job address _4851 E. Woodbridge Rd CityAcampo ,_ Lot Size PM Owner's Name Bon & Ardith Biffel Address Same Phone 369-1819 Clat Well 2024 E. Charter 371560 462-7676 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS PUMP INSTALLATION RX SYSTEM REPAIR ❑ OTHER ❑ jUC.) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS [71 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } I'] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout A I I Irrigation -Approx. Depth t I Eastern Surface Seal Installed by �\ Repair Work Done ❑ Type of Pump Sub H.P. 2 State Work Done install Well Destruction RX Well Diameter Err Sealing Material (top 501 9 sack Depth na Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION E 1 REPAIR/ADDITION l 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 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 I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 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 Cali rni The applican s allall r d ions. Complete drawing on reverse side.„ 'g- P Signed Title:r_lr]C X11 UP Date: `FO DEPARTMENT USE ONLY Application Accepted by �. w4a z.,�e a,��.� Date Area Pit or Grout Inspection by '� � ' ' ;;_ `-Date ! s -S Final Inspection by Date 11 1 Additin,s z.!Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH 14-28]REV.1/85) �'r� 4�