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ter. APPLICATION FOR PERMIT SAN JO AQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZELTON AVE., STOCKTON, CA DEC 7 30089 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �;. / n S f't�i�i,flI1/SE;;1�It ES I (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 485 . East Woodbridge City�AC )MlJO Lot Size 1 C PM I owners Name Bob Biffel Address 4851 East Woodbrid e Phone 20c)—'569-1810-, North Valley Drilling, InC,P.O . Box 108 0 7 Contractor Address Corning� Calif.,,602L4icense No. 418834 Phone a 9l6,-824-a 6.2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0� DESTRUCTION ❑ PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ _OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _50"' _*' SEWER LINES DISPOSAL FLD. 5 01- PROP. LINE 'I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 pit Dia. of Well Casing IXDomestic/Private ZI Gravel Pack ❑ Tracy Type of Casing 1022'a Ste-e-1 Specifications n Public ❑ Other ❑ Delta Depth of Grout Seal t -1-449 Type of Grout nP,9 t I I Irrigation 4MrApprox. Depth I I Eastern Surface Seal Installed by RA,Tid sp-;:33 - Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material Molow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION I I DESTRUCTION l I (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 4, 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 l 1 Depth Size Number SUMPS Cl - Distance to nearest:' ..Well""""' Foundation .Property Line DISPOSAL PONDS ❑ A 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 sha 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 applicant must call for ail require inspections. Complete drawing on reverse side. Signed X Title: 2ec Date: 12-5-89 ffFOR DEPARTMENT USE ONLY Application Accepted by Date 'µ L u Area +" Pit or Grout Inspection by +� Date Final Inspection by Date Additional Comments:* � 01 ��~ 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 104 ❑ Tracy 835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT NO. INFO f r ' i EH14-28iREV.tiH5r