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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Job Address 5771 W.' Turner Rd. city `Lodi Lot Size PM { Owner's Name Gale -Rees Address 5771 W• Turner Rd. Phone( 209)334-34551 ContractgdWard J. Ambr°ogio Address 229 .Folarth St`. ,Galt License No360652 Ph.R,209)74+ -15 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES r, DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL * PROBLEWI AREA ,, CONSTRUCTION SPECIFICATIONS ❑ Industrial $Cl Open Bottom ❑ Manteca iia df Well Excavation pia. of Well Casing '7 Domestic/Private ❑ GravelPack '❑ Tracy' Type of Casing Specifications ❑ Public ❑ Other ❑ Delta_ .. Dep-th-of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastem`'w._' = 'Surface Seal.Installed by Repair Work Done ❑ Type of Pump Sub. H.P. V4hp ., �� ' State Work Done install pump � f ' Well Destruction ❑ Well Diameter t Sealing Material hop 501 r f , ._ .,. E-,,•r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is { l available within 200 feet.) J Installation will serve: Residence_- Commercial Other ) Number of living units: Number of bedrooms ' I Character of soil to a depth of 3 feet: —Water table depth SEPTIC TANK ❑ Type/Mfg ._Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines E T Total length/size 1 FILTER BED ❑ Distance to nearest: Well ---�'F.oundation Property Line 1 M1 SEEPAGE PITS ❑ Depth Size Number } SUMP$ ❑ Distance to nearest: Well Foundation Property Line i 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 California." The applicant must call for all quired inspections. mplete drawing on reverse side. ~ Signed X Title: Edward J. Ambrogio owne&., May ,2, 1956 FOR DEP MENT USE ONLY 7 II Application Accepted by Datec Area —2"' ev 1 Pit or Grout Inspection by rr-- Date Final Inspection by I Date Additional Comments: • i✓-E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 825-71040 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEKi INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH13-24fREV.i/R5) $35.00 4135.00 #2393 5 EH 14-28 - �\