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f APPLICATION FOR PERMIT ;x E�- ,, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 7� - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h escribe T application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules a�u�t�n San Joaquin Local Health District. �fl�if �� LHI Job Address - � - City OLCl Lot Si M'.sv CoA s rr u e.-tr d ll: Co Owner's Name erg Address DC�r1 f G G7 Phone 2 Z -.� .SS .;F 2; `4r�06 .277 638 7 7(� ; Contractor 1 ,fir.f�[ ss °23 License No.�SS�Iq�.- one N } �. Tim�kkhRUMP: N L1&110vj SO 1 PUMP INSTALLATION ❑ SY REPAIR ❑ OTHER �I��2i`'r��✓155 SEPTIC TANK SEWS E5 DISPOSAL FLD. PROP. LINE i i S FOUNDATION (CULTURE WELL OTHER WELL PITS/SUMPS SE AUiA TY ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ ..'Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s f i P tic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I _d It- Irngauon .�Q-LApprox. Depth l I Eastern Surface Seal Installed by 1W 15A.6a C&LiiAe Repair Work Done ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 -- REP!IF i ViaTION I I (No septic system permitted if public sewer is I �] available within 200 feet-) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth i 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 SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 DiMrict. 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 i 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�Kz"%AR6 ctions. Complete drawing on reverse side. Signed X �u —d—Al -- Title: —P—,",j EL Date: !ra— 10 f4e" IiCa �1.tiv. aSSesSof Cd-C� P N7 USE ONLY Application Accepted by �/ �+� Data r Area Pit or Grout Inspection by k L�/lit 9'� _ Date Z J G'Final Inspection by Date v Additional Comments: '�`�'`"LL ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tray 835-6385 Applicant - Return all copies to: Environm ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH EH 13-24 ISM I/m51 EH 1428