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a i 5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA „Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in .Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 10611 W. 'Wal ntiit'�Grove 'Rd• �;ty TnOrri on Lot Size PM Owner's Name Aurora DaGaria _ Add�ess�-06 1 W: Walnut -Gree .Rd.ffihoFp eon 794- 2109 „ Contractor Edward J. Ambr09'Rddress 229--4th St. t Galt Ca. 360652 745-1.53fS, License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, _ DISPOSAL FLD. PROP. LINE t 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public = ❑ Other ❑ Delta Depth of Grout Seal Type-of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by m.l f -..,i Repair Work Done 11� Type of Pump H.P. 2 T State Work Done 1 • putlap G orine Well Destruction ❑ Well Diameter Sealing Material (top 50') drill & ap"WD er Samp.dev CQ Depth Filler Material (Below 501 PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wr e: Residence Commercial— Other. - Number of living units: Number of bedrooms Character of soil to a depth of-3 fee . --- Water table depth SEPTIC TANK LlType/Mfg ) Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation, Property Line LEACHING LINE ❑ No. & Le gth,of lines !� To th/size FILTER BED ❑ .Distance to nearest: +Well Foundation Prope i SEEPAGE PITS ❑ Depth _ Size Number SUMPS f ❑ Distance-to-nearest:---Well":'_ F61 n`datO i"' ""Properi,76n-e 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 imthe 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 ust call for all r u' inspections. Complete drawing on reverse side. Signed TRIZQntraetor Edward J.Ambro o I-lar ch 27, 1986 FOR.DEPAR IENTiVLY // Area Application Accepted by Date _ 3:7 !`Jim m Pit or Grout Inspection by Date Final Inspection by Date �__;Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Perrrlit/servict6nl E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH KRECEIVED BY DATE PERMIT NO. + EH 1EV. /:3 51 ' !f S�� Z+� � 9, ^1 O�o EH 14-28 4-ZB '