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' F ► APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 (Complete in Triplicate) i 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. parcel #025--150-26 Job Address50O ' West O t Morf-h Saraen t mad - -- PM Owner's Name Andrew LeoUardini Address ._�3 Phone Lodi, Ca 95240 Contfacto`pLirVlariCe Dr111e jAddTeI§Co se No.377q23--Phone 8197-3954_ TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHER WELL-- PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 1-1IndustrialJR Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 12 3 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications X -188 I-1 Public ❑ Other 71 Delta Depth of Grout Seal Go— Type of Grout _ XIrrigation 200Approx. Depth I 1 Eastern Surface Seal Installed by —0— Repair Work Done ❑ Type of Pump H.P. State Work Done (� Well Destruction ❑ Well Diameter Sealing Material Itop 501 �S 4 Depth Filler Material IBelow 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public-sewer is available within 200 feet.] [r� 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 n 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 l 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 subcontracting 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 p0cFa_n9Tys1 call red inspections. Complete drawing on reverse side. Signe Title: Car . Secretary Date: 9Z23/88 %, FOR DEPARTMENT USE ONLY Application Accepted by Date Q Pit or Grout Inspection by — �✓ Date lb ie Final Inspection by Date IA [�` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 C7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Q CASH RECEIVED BY DATE PERMIT NO. INFO ' +.EH13.24(REV.I/A5) EH 11-2a