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aLARfi E'S SEPTIC SEt°JcR SERVICE SAN FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 26, So aro x.� Stocktog, Calif. 95205 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. FII.463-3209 I;DR2fa,CtOr'S L ic.�26717A Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a 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 n J aqu.{n Local He h District. Job Address .a pbdivision Name �1 ,�. Lfr.� ,�C Address �o� �� Phone i Owner's Name ✓ Phone Contractor's Name i - License No. 93 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: 'SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED.USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing [].Public Other- ❑Delta �' f Type of Casing Ll Irrigations . Approx. ❑Eastern , Specifications ;.« Depth [:]Cathodic Protection i. ,. Depth of Grout Seal kl } ?�. ❑Geophysical Type of Grout it ' i U Other Surface Seal Installed by State Work Done ` Repair Work Dane ❑ Type of Pump H.P. � Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit avai ableed if withinu200csewer feet.) is Installation will serve: Residence Commercial _ Other h �. Number of living units: Ni of bedr om` o Lot size Character of soil to a depth of 3 r Water table depth !� SEPTIC TANK Type/Mfg � Capacity� Cg2 No. Compartments G PKG. TREATMENT PLT. ❑ ' ;.fype/Mfg Capacity Method of Disposal Distance tear s Well Foundation Property Line LEACHING LINE U No, & Le gth of lines Total length/size { Property Line FILTER BED ❑ Distance to nearest: Well Foundation P SEEPAGE PITS [] Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS L4 • 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 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% 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.compensation laws of California." The applican =s .all for all req iced ins [tions. Complete drawing arse Signed X Title: 1�1'r� .rr✓1 Date: EPR DEPARTMENT USE ONLY /� 5tk 466-6781 Application Accepted by Area Additional Comments: EJ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rl EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. t NFO 10/82 500 EH 13-24 REV, 10/82 14-26