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/ + APPLICATION FOR PERhIIT 14 S4N JOAQUIN LOCAL 4:4LTH DISTRICT 1601 E. 4AZ LION AVE., STOCKTON, CA PERMIT NO. __�_:S 7 CLARE«CE'S SEPTIC & SEWER SERVILE Telephone ;209) a65-6781 DATE ISSUED _ -_]=t3 263 S0. Oro 4 Stockton, Calif. 95205` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ph. 46,3.3209 Lontractor's Lic. #267.173 (Complete in Triplicate) i Application is hereby made to the San Joaqu'n Local Health District for a permit to construct and/or install the work herein described. This application is made jr. compliance with San Joaquin County Ordinance No. 549 'or sewage or No. 1862 for well/pump and.the Rules and.Regulations of the San Joaquin Local Health District. i Subd'vision Name — Job Address +� (V + ' Phone 1 0 � Address e� owner's Name Phone — Contractor's Name 5:: License No. WELL REPLACEMENT ❑ DESTRUCT;ON's TYPE OF WEL./PUMP WNEW WELL ❑ PUMP INSTALLATION r SYSTEM REPAIR 17 OTHER U SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK —� _ OTHER WELL P'TS/SUMPS FOUNDATION AGRICULTURE WFLL INTENDED USE TY7E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack �—iTracy Dia. of Well Casing _ C] Public Other Delta Type of Casing Lj7 Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Lf Other Surface Seal Installed by Repair Work Done [� Type of Pump H.P. State ''Work Done Sealing Material (top 50') Well Destruction Well Oianeter, Depth j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/AUDITION j (Ido septic tank or seepage p�availableewithid if nu2DOcfeet.) is I Installation will serve: Residence -1`''�y Commercial Other Numocr of bedrooms f-� Lot size Number of living units: Water table depth —,g—r-- Character g _Character of soil to a depth of 3 feet: Capacity No. Compartments III SEPTIC TANK Fj Type/Mfg d of Disposal PKG- TREATMENT PLT. [1 Type/Mfg CaMethod pacity Line — SEWAGE SYSTEM Distance to nearest: ldell Foundation _ Property �1 DESTRUCTION Total length/size V Yr. -;7. --LEACHING LINE No. & Length of lines f"' Foundation f� r Property Line -- FILTER BED Distance to nearest: Well �- 01 SEEPAGE P1T5 �' Depth Size -.r Number _ foundation / Q r 'Property Line S SUMPS Distance to nearest: Well /_— — DISPOSAL PONOS ❑ -� G 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 Q`• the Sar. Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance ns the work for which this following:certify performance of the work far which permit is issued, I shall not employ any person in such manner as 'o become subject to workman compensation laws of California. Contractor's hiring or sub -contracting signature subjectcertltoewo kmans the scompensationlaws of California." this permit is issued, I shall 'employ p r se si The applicant m t c 1 for all req Ir inspec ons. Complete dra "rig Date:_ Title: Signed X FOR DEP RTMENT USE � Area S Stk 466-6781 Application Accepted by _�--� — — Lodi 369-3621 Additional Comments: Date Manteca 823-7104 Pit or Grout Inspection by �PerTrit/ LTracy 835-6385 DateFinal Inspec_ion byApplicant - Return all copies to: 201 Environmental Heices 1601 E- hazelton Ave., P.O. Box 2009, Stk., CA 95 FEE I PERMii N0. BASE AMOUNT DUE AMOUNI REMITTED RECEIVED BY DATE INFO EH 13-24 REV. !0/82 14-26 10/82 500