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APPLICATION.F OR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTSly s 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' w�e�. tt sf r .,,�, 27381 N. 'Blossom';jRd. ��" Job Address " Cit 'rlOY'i1tOn Lot Size RM Owner's Name Sarah Goldman- " Address Same 7` -T Phone x'5-2533 Contractor-`dward J• AmbrobioAddreSS 229--4th St. )Galt Ca..Lieense No.3 60652 Phone 745-1531 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation :___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work D ng concrete am r casing Well Destruction El' Well Diameter Sealing Material (top 50') re Sea�ing7UII1jJ C' Orarze Depth ^: Filler Material (Below 50')> TYPE OF SEPTIC WORK: NEW,INSTALLATION L1REPAIR/ADDITION ❑ DESTRUCTION LJINo septic system permitted if public sewer is I available within 200 feet.) W o Installation will serve: Residence_ Commercial_ Other 00 • Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , j %/ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ` ❑ No. 8 Lengthof.lines• Total length/size LA r.,, FILTER BED, ❑ Distance to nearest:�- Well r Foundation Property Line A u" SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:- Well Foundation- 4.T- `Property Line r DISPOSAL PONDS ❑ I 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, an 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, l shall not employ any person h�such manner as to became subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature t 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 o of California::' - "�! The applicant must call for all requi pectio Complete drawing on reverse side. Signed X -Title: ContractorEdw.J.AMbr0g:6Q,: Narch 27 1985 <' -FOR D`E ARTMENT USE ONLY i Application Accepted by. _ �: Date Are f Pit or Grout Inspection by Date' ""} Final Inspection by Date 7-7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi} 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 " Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F { INFO AMOUNT/UyE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + ENI 13-24 IREV.tMiorel EK 1429 l� 10 6.