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{ t 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 4 (Complete in Triplicate) I Application is hereby made to the Sanf 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 Roles and Regulations of the San Joaquin Local Health District. 20t ae Jab Address 3623 y r s' 2 ct 'l —.4 City Loi Size - PM �R y. Owner's NameFRANK ALBERTI�.�mow. - Address 13707. 1X DAVIS :,RD Phone 369-2663 - . Contractor KEITHGROSS Addrespo BOX 178 'W00DBRIDG�icense Na. X77385 Phone 334. 4725 . TYPE OF WELL/PUMP: .- ANEW WELL -IE* t WELL REPLACEMENT t- DESTRUCTION ❑ PUMP INSTALLATIOPrT SYSTEM REPAIR ❑ OTHER ❑ 150 DISTANCE TO NEAREST: SEPTIC TANK 1 10 SEWER LINES _1 1�' DISPOSAL FLO. PROP. LINE _ r FOUNDATION AGRICULTURE WELK: OTHER WELL PITS/SUMPS -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEFICATIONS 6 ❑ Industrial ❑ Open Bottdm'- ,0 Maeca{ E Dia. of Well Excavation Dia. of Well Casing 'UDomestic/Private *0 Gravel-Pack';--- � Tracy , P- -Type of Casing_StP.P- Specifications ❑ Public ❑ Other ❑ Eiee ` •-. Depth•,of Grouf'Seal- 1� Type of Grout ,__ -- • ! ❑ Irrigation 1 2i�Approx. Depth ❑ Eastern i Surface Seal-Installed by Repair Work Done ❑ Type of Pump._ .-..- H.P. State Work-Done - Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION Ll DESTRUCTION ❑ (No septic system permitted if public sewer is j c 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: s Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LlMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE -- C7-_-No.-&-Length-of-lines— -- —Total-length/size FILTER BED ❑ Distance to nearest: Well Foundation Propaearty Line i SEEPAGE PITS --'O—Depth= Size, x Number. ' SUMPS t i C1Distance to'nearest'. f Wed Foundation Property Line DISPOSAL PONDS -2- I hereby cert'rfy,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 orflicensed agent's "signature certifies the-following: "I certify that in the performance of the work for which this permit is issued, I11hall not employ any person yin such manner as to.become subject10 workman's compensation laWslof California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance 0.1he work for which this permit isyssued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call r all r uired inspections. Complete drawing on reverse side. Signed i'GdK� Title #OWIE, f Date: 2—ZL�"'$7 3 FOR DEPARTMENT USE ONLY �/ Application Accepted by Date � _ AreaAa r 1 Date Final ns ection by'� at / ' Pit or`G�4uilnspection by p Additional Comments: ; ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return allcopies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, 5tk7 CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT INFO + EH 13-24 IREV. /a s) �. , 13s/ 7_Z ' EH 14-26