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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 # ebl4 i 13 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,I:p .�119goiq ole:,. �^ (Complete in Triplicate) t, .Tirris app cation is Application is hereby made to thurn Local Health 0 d Hance No.District549 for sewage or It to No. 1862 forcwell pump and the Rules and Regulatiot and/or install the work herein ns of he San l Joaquin made in compliance with San JoaquinCounty ,. . Ry+ 11% Local Health District. 2 81 e N Blossom Ra§.fic# k=� %qq _'Thornton 5 �Lot-Size PM Job Address �•� `�. amen ,- - Phone 745-2533 . Owner's Name Sarah Goldman-v- ` -Address Y e , Galt?C i 360652 745-1531 Contractor Edward J . Ambrog'%dress 29-4th Sttense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 'lDia. of Well Casing E� ❑ Manteca Dia..of Well Excavation ons yg E3 Industrial u❑'Open Bottom ---<--�� T e of Casiri�"�"4 Specifcati �, DomesticlPrivate CYGravel'Pack ❑ Tracy yp 9 ► Type of Grout f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i . d by Irrigation ---Approx. Depth ' Eastern Surface Seal Installe CI COT1Cre te ,arijcT.ca sin r "` H.P. "" - State Work-Done 'R Repair Work Done Type of Pump .f.. . .. '&sea We .,Sea Cl Or1nG' { ` Well Destruction Well Diameter Sealing Material;Itop 50'i 4� t "' Filler Material {Below 501 1 Depth mi(No se' sm per TYPE OF SEPTIC WORK: NEW INSTALLATION L-1 REPAIR/ADDITION ❑ DESTRUCTION Q availablelwithin 200 feet.jed rf public sewer is t Installation will serve: Residence Commercial. Other t Number of living units: Number of bedrooms Water table depth'"'w Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK 1-1 Type/Mfg Capacity = Method of Disposal k PKG. TREATMENT PLT. ❑ Distance to nearest: Well iFoundation 7` r ' Property Line; v _ Total length/size LEACHING LINE ❑ No.:'& Length of lines,. r r ; FILTER BED C1,. Distance to nearest:. Well Foundation 'Property Line , O - l t 0 i Y Number SEEPAGE PITS ❑ Depth i SUMPS C1Distance to nearest:. Well Foundation Property tine DISPOSAL PONDS ❑ ! 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. for which this permit is issued, I shall not k. Home"owner or licensed agent's signature certifies the following. "I certify that in the performance of the work 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 ail re j ed inspe ions. Complete drawing on reverse side. ,;r "'"�" s T;tle: CoritraCtor:Edw.J.Ambro Vie: March 27, 19$6 . Signed X T FOR DEPART 1117 USE OILY ,�. ^' .. 1✓((� Area Date Application Accepted by a l -y Date 7 s 6 Pit or Grout Inspection by Date Final i.Inspection by ! Additional Comments: .: ❑ Stk 466-6781 17 Lodi 369-3621 ` ❑-Manteca B23 7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEECK RECEIVED BY DATE PERMiT'NO. AMOUNT DUE AMOUNT REMITTED CASH + EH 13-24 4REV. 5} EH 14-28