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-" C1APENCr'S SEPTI% &- SEWER SERVICE <br /> APPLICATION FOR PERMIT 2�3 o. <br /> C€.ARENCE'S SEPTIC & SEWER SERVICE Sto" ;gun Ge;lif. 9"5205 <br /> 263 So. Oro � Stockton, Calif,;°95205 SAN JOAQUIN LOCAL HEALTH DISTRICT i�" ?r; .. 20 77 <br /> l•46 ," 2x9 ContrectflC'�LIC. 26717 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> � <br /> 4 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> li <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein <br /> described. This application is made in compliance with San Joaquin "County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the n Joa uin Local Health District. <br /> Job Address 15 ubdivision Name <br /> Owner's Name ' I! �- Address Phone <br /> Contractor's NOcense No. Phone <br /> 'IT- 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL t WELL REPLACEMENTr <br /> q _ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom E]Manteca Dia. of Well Excavation <br /> 17 Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> L] Public r-1 Other Delta <br /> Ll Irrigation Approx. Eastern Type of Casing <br /> Depth Specifications <br /> L <br /> Cathodic ProtectionDepth of Grout Seal ' <br /> Geophysical ;II --- <br /> Other �; Type of Grout <br /> Ip Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth .I. Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 9 (No septic tank or seepage pit permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation -will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms _ Lot size e& . / ` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method,:of Disposal <br /> Distance to nearest-, Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines _ � Total length/size `fa <br /> FILTER BED Distance to nearest: Well Foundation 'Property Line - <br /> 4 SEEPAGE PITS Depth Size . Number _ <br /> SUMPS u Distance to nearest: WellFoundation, Property Line S"`r <br /> DISPOSAL PONDS <br /> i <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and"rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman S compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> The applicant t 11 for;,all r u' in ctions. Complete draw- g on a erse si e. <br /> Signed X--�� Title: Date., <br /> MEQ TMENT USE ONLY <br /> Application Acceptedby T � "/ Area �5tk 466-6781 !!! <br /> Additional Comments:'I ❑ Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 i <br /> Final Inspection by i� DateTracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> {9 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 fid Q� <br />