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APPLICATION FOR PERRL SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hm..sv made to the San Jo.num Local Health Dist,ct for a permit to construct ar.:or install the work herein described. 1 Onhis Sets Joaquin n made in compliance with San Joanuin Counry Ordmarve No.549 for sewage or No. 1962 for well/pump and the Rules and Regulation o6 tM San JoarRdn Local Health D::1rict. �E u If n ,,,�.,,.s.� Job Address •Z. 6 > ! S. U h.�i' O N tel— City J"rte">_=G+}cr.^.iza IM i -2-6 Z_7 57 Phone w I Oner's NameF�-A-v1 - License No. Phone Contractor Addle, f iW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O j TYPE OF W[LL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ PUMP INS1N*:b.TION ❑ PROP. LINE - SEWER LINES DISPOSAL FLD.� DISTANCE TO NEAREST: SEPTIC TAN'. FITS/SUMPS FOLINDATICN _ rGRICUL?URE SELL —_. OTHER WELL -t INTENDED USE TYPE OF WE!L PROBLEM AREA CONSTRUCTION SPECIFICATIONS Did.of Wag Caning ❑Industrial Open Bottom ❑ Manteca Dia.of Well Excavation Speci6catbns ❑ Domestic/Private ❑ Gravel Pack C Tracy Type of Gsing - M Public fl Other fl Della Oepth c. Grout Seal Type o/Gruut I I InigatkR. —AppnOY. Depth I I Eastern Surface Seal Instilled by I Repair Work Done L3 Type of Pump H.P. State Work Don__ C Well Destruction C Well Diameter Sealing Material IMP 501 _.— Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/AOOITION I DESTRUCTION 1 I INOava "Ptable tC Susi n flit'ed rl pudic sewer is Installation will se.ve: Residence4�Commerciai_ Other + Number of living units- Number of bedrooms L�-- i Character of sod to a depth of 3 feet: Lid n""k Water table depth SEPTIC TANK m/Type/Mfg `�"L Goy e'V CTC, Capacity I j a O No.Compartm m PKG.TREATMENT PLT.❑ / ,n x Method of DispO�al r '� E Distance to nearest: Well SL_ Foundation Property Lina r ¢ .. a T tel tength/six6 1 q� —,,1 !r LEACHING LINE Ll No. 8 Length o/lines Z FILTER BED �Oistance to nearert: Well�.� Foundation Z tg Property L'we — i SEEPAGE PITS I I Depth Size __ Number SUMPS LI Distance to nearest: Well Foundation__ Property Line DISPOSAL PONDS I hereby cenity,that I une prepared this application and that the work will be done.n accordance with San Joaquin county ordinances.state Ines,erss rules and regulations of the San Joaquin Local Health D3rrict. Home owner w licensed agent's signature certifies the following:"I certify that in the pedormanca of the work for which M'r,pamlit is issued.I shag not emp'py any person in such manner as to become subject to workman's compensation Lewis of ed.California-"saillContractor's hiSubi a f1Dtpnrsaeting shilsawm me certifies the following:"'1 certify that in the Performance of the work for which this permit is issued,1 spell em.:!ny persue subject to workman's corrlparrsa t tion laws of California:' r The applicant must tilt for�!I required inspection. mplate drawing w reverse side. 'R /1C1 f� Title:�--a–..�" — Date: /- �'�'l!•'•, toe/ OR DEPARTMENT USE ONLY [xA / Application Adapted by Date 0 � Atea77 Pit or Grout Inspection by / Date Final Inspection by or 0 St466-Ml Comments: ,A Stk 4666781 ❑ Lodi 369-362 O Manteca 877-7104 ❑Tracy/815-6185 Applicant- Return a"copies to: Environmental Health Permit/Services 1601 E. Herelton A".. P.O.Box 2008.Stk., CA 95MI ' FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PER NO. .`t. INFO