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APPLICATION FOR PERMii l SAN JOAQUi!i LOCAL HEALTH DISTRICT 1601 E. HAZELTON 4VE., STOCKTON, CA PERMIT N0, S 7 F° CLARENCE'S SEPTIC & SEEWER SERVISE Telephone (209) 466-6181 DATE issuED 263 So. Oro * Stockton, Calif. 952451 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ph.461.3209 LontFactof's Lic.#261.17 -(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump described. This application is made and,the Rules and.Regulations of the,an Joaquin Local Health District. Job Address Subdivision Name 0 _i0W '1 �'� + Phone o� Owner's Name Address phone uJ Contractor's Name License No. t : TYPEOF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR 1-11 OTHER U } . OP. LINE DISTANCE TO NEAREST: SEPTIC TANK,- ��.. SEWER LINES OTHER WELL PITS/SUMPS D15POSAL FLD. PR O?. LINE FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open l❑ Industrial Bottom 71 Manteca Dia. of Well Excavation k. l Pack F-1Traey Dia. of Well Casing ❑ Domestic/Private F-1 Grave ❑ public ❑ Other ❑ Delta Type of Casing Eastern Irrigation Approx. ❑ Specifications Depth I ❑Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by H.P. State Work Done Repair Work Done ❑ Type of Pump, '0 Well Destruction ❑ Well Diameter.., Sealing Material (top 5 Depth j Filler Material (Below 5 50') TYPE OF SEPTIC WORK: NEW INSTALLATION F1 �` REPAIR/ADDITION Q'�(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) OD Installation will serve: Residence _X1 Commercial Other 1} Number of bedrooms .L— Lot size p Number of living units: Water table depth f Character of soil to a depth of 3 feet: r Capacity No. Compartments cl SEPTIC TANK ❑ Type/Mfg Method of Disposal S PKG. TREATMENT PLT. L] Capacity Type/Mfg property Line SEWAGE SYSTEM Cl to nearest: Well Foundation DESTRUCTION No. & Length of�line, Total length/size LEACHING LINE O ?' Property Line FILTER BED I❑ Distance to nearest: Well _ Foundation De th; _ Size �"? ` P Number r SEEPAGE PITS1/0 Proper P • ty Line SUMPS U Distance to nearest: Well/ Foundation DISPOSAL PONDS ❑ I G epared this application and that the work will be done in accordance with San Joaquin county I hereby certify that I have pr ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner orli ensed certifies the suchFinannernas to become subjectthantohworrkman+ compensate performance of lionwlawsfof California." k permit is is "T certify that in the performance of the work for which Contractor's hiring or sub-contracting signature certifies the following: this permit is issued, I shall 'employ persons subject to workman's compensation laws of California." � se sid p. f The applicant m t c 1 for all requir inspec ons. Complete dra ing pate: Q ,Z +� Title: Signed X FOR �P RTMENT USE Area ' Stk 466-6781 Application Accepted by ❑ Lodi 369-3621 Additional Comments: ❑Date Manteca 823-7104 Pit or Grout Inspection by Date tr, _ Q - fr X ❑ Tracy 835-6385 Final Inspection by s _rte-=1=�ti 201 Ave., P.O. Box 2Q09, 5t k., CA 95 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton FLFEEBASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT NO. G5 10/82 500 j EH 13-24 REV. 10/82 14-26