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le APPLICATION-FOR PERMIT �44a SAN JOAQUIN,LOCAL,HEALTH DISTRICT r 1601 E. HAZELTON ON AVE., STOCKTON, CA Qom►"" 1 ` Telephone (209) 466-6781 1 PERMIT EXPIRtS 'I 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 2 73 U1 1,i * BlO S S= Rd,' CityThorllton Lot Size PM Sarah Goldman Sane71 -2 Owner's Name Address Phone ��r �3J Contraci8 Award J . Ambrogio Address 229-f�th 3"t. 7 Galt-L lItense No. 360652 Phone 1 715_1J31 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCT4ON ❑ PUMP INSTALLATION Ll SYSTEM REPAIR 1:1OTHER fe 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 ID Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done 16� Type of Pump H,P. State Work Done cofLCre to a.rnd,casin Well Destruction Q Well Diameter Searing Material(top 501 8 Seal Ld4ll seal c? Clorin Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) J Installation will serve: Residence— Commercial— Other uy 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 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 0 SEEPAGE PITS E1 Depth Size Number V1 SUMPS (a Distance to nearest: Well Foundation Property Line N DISPOSAL PONDS ❑ A 1 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 3 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- lion laws of Cal-nia." The applicant roust call for all re ed insp ctions. Complete drawing on reverse side. Signed x , x:12 _ Title:Contraci or ,Edw.J,Amhrogioate; iMarch 2 19 6 FOR DEPARTMENT US ONLY Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection by Date /7—yY Additional Comments: � ygiilez�l ale, ❑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.Q. Box 2009, Stk., CA 95201 IFEEO AMOUNT OU�rE AMOUNT REMITTED) CCAK It RECEIVED BY DATE PEAMIT'NO. t EH 13-24(REV.1l H 5) EH 11.28 /V 5••✓ r�f O\p