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CIRRENCE'S SEPTIC & SEWER SERVICE APPLICATION FOR PERMIT 263 SD Oro k: Stockton, Calif. 95205 SAN JOAQUIN LOCAL HEALTH DISTRICT Ph.463.13209 Contfactor's Lic.#267173 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete, in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein n described. This application is made icompliance 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. a-� Job Address� �'� Lit��y.,�'.�`' �"Subdivision Name''. Owner's Name Address / �` Phone .' Contractor's Name ..,* _ License No. Phone j x T TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi i Y I Industrial - Open Bottom [-]Manteca Dia, of Well Excavation ' Domestic/Private - L� []Gravel Pack [� Tracy Dia, of Well Casing L7 Public �j Other Delta LJ Irrigation ' Type of Casing Approx. �' � Eastern Specifications r Cathodic Protection Depth r LJ Geophysical Depth of Grout Seal L Other r- Type of Grout y Surface Seal Installed by— Repair y Repair Work Done El Type of Pump. w H.P. State Work Done ' - We1,1 Destruction,() Well-Diameter-ter 'Sealing -- . =� Depth ' ° ' s Filler Material (Below 501) ! TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION_C-_(Nosseptic tank or seepage pit ,permitted ifspublic sewereis `available within 200 feet.) Installation will serve: Residence r Commercial Other " Number of living units: —f=- 4Numbe`r•of bedroom •y Lot size - Character of soil to a depth of 3 feet _ °M- Water table depth p �R SEPTIC TANK Type/Mfg , ;� apacity 49r,� No. Cam artments PKG. TREATMENT PLT. Type/Mfg _ * - ,. `- Capacity • Method of Disposal Distance to nearest: We11'' Foundation Property Line > LEACHING LINE No. & Length of lines . ✓ Total length/size ,�;t„ -y. M` •: FILTER BED Distance to nearest: Well Foundation Propert SEEPAGE PITS " Depth � P Size r Number SUMPS Distance to nearest: Well tax` 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 i ordinances, state laws, and rules and regulations of the San Joaquin Local Health,.District. - s Home owner_,'or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit'i-s". ssued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor' s'hir_i.ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this,permit'I's issued; I-shall employ persons__subject to workman's compensation laws of California." The applicant must call for all required. inspections. Complete drawing on reverse ode. ,,, -Si. ed..Xjar .__ r �(`' Date: R DEP TMENT USE ONLY G Applicat�on,Accepted by Area Stk 466-6781 + Additional Cormt ts: /� - 5G'�G B�� Lodi 369-3621 Pit or Grout Inspection byate f 1.3'--SZ- Manteca 823-710_4_ _ w _ -final. Inspectionkby,, s Date /,2--/°J -k? •Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA. 95201 s. ` E FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. J INFO EH 13-24 REV. 10/82 14-26 Y10/82 500 W