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TSO <br /> APPLICATION FOR PERMIT t �� <br /> SAN JOAQL;N LOCAL HEALTH DISTRICT PERMIT NO. 'M"`t 30 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ED -7 <br /> PATE ISSUED <br /> CLARENCE'S SEPTIC & SEWER SERVIEB Telephone (209) 466-6781 <br /> 263 So. Oro _III;, Stockton, Calif. 95205 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ph.463-3209 CDntractcJ'sLic.#2&ZIIl� (Complete in Triplicate) <br /> rein <br /> Application is hereby made to the San ]oaqui�iancelwlithlth SanDistrict <br /> Joaquin Countypermit <br /> Ordinance construct <br /> forand/or <br /> sewageinstall <br /> Noth1862rfor ewell/pump <br /> described. This application is made in comp <br /> and the Rules and Regulations of the San oaquin Local Health District. <br /> Subdivision Name.,. <br /> Job Address Phone <br /> Address ��� 20 <br /> Owner's Name Phone <br /> Contractor's Name <br /> License No. <br /> xDESTRUCTION <br /> NEW WELL WELL REPLACEMENT �� ❑_ � <br /> TYPE OF WELL/PUMP WORK: ❑ E OTHER LJ <br /> PUMP"iNST LAi�9N��"�TS1SiEM-RfPAI'R— ^"" DISPOSAL FI-D. PROP. LINE-- <br /> k s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITS/5UMP5 <br /> I FOUNDATION + AGRICULTURE WELL <br /> 4 <br /> PR06LEM AREA"----.. CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL ,j <br /> Manteca sDia. of Well Excavation <br /> �J Industrial U OpeS Boato <br /> I Gravel Pack, Tracy orWe1-,Casing <br /> } U DomesticJPr-i-vate-� J <br /> E L7 Public Other a 0 Delta? ' Type`of'Casing <br /> �jirrigation �Approx. Eastern Specifications t <br /> Depth .... <br /> ,�,•-.;.moi <br /> � athodic Protectio��t � <br /> ' y Type of Grout 3 "� } <br /> geophysical <br /> '• U Other i Surface Seal 1 stal.l ed by, <br /> f I I <br /> T e of Pum H P t.> State Work Done' I <br /> { <br /> Repair Work�Done yP I p, /(C G <br /> L Sealing Material (top <br /> well Destruction Well eter <br /> It <br /> Filler Material (Below 50') SAN f�. C t2 E _Y <br /> S ' Depth It <br /> { j <br /> REPAIR/•ADDITION (No septic tank or seepage pit permitted of public sewer is <br /> TYPE OF SEPTIC WORK: INEW INSTALLATION ❑ availa11! ble within 200 feet.) <br /> a , „• / � r <br /> 1 I Commercial Other V Z . <br /> Installation will'.-serve: Residence <br /> i i Lot size /s s <br /> i 1 Number of living units: 7 Number of bedrooms <br /> i � � Water table depth J! p <br /> a aracten of s6i1,to ,a eDh of 3 feet: Capacity __�_ No. Compartments �j <br /> I SEPTIC TAN_K_16-, � b/Mfg Capac ity Method of Disposal f <br /> I I PKG` TREATME-NT LT. Type/Mfg Property Line F <br /> Foundation <br /> j SEWAGE SYSTEM DisIance to nearest: Weld f <br /> eA- <br /> EDESTRUCTION Total length/size ! <br /> k LEACHING"L1M13E No:4& Length of 1 ineS <br /> ` Foundation Property Line <br /> FILTER BED ❑ Dis`tance to nearest:. Well <br /> 3 t' Number <br /> k ..,w r,Depth —���_ Size � <br /> 1 <br /> SEEP, <br /> PITS 4 Property Line S i <br /> SUMPS L1 Distance to nearest: Well �� Foundation <br /> I � - <br /> y i . <br /> DISPOSAL PONDS _ . <br /> - <br /> I�be eby certif; that I hdy_eFprepared this application and that' the work will be done in accordance with San Joaquin county <br /> 1 <br /> E ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t <br /> ensation laws: of California." <br /> : ,,,: Rome owner or licensed dgent'islsignature 'ceeson1in suches the rmannernas to becomeys_ubjectthat ntohwopkmanR c�erformance oferformance of the ktherworkcforhwhich <br /> /permit is issue�y i sha41 not employ any p ; certi;fy'that in-the_p <br /> ' Contractor's hiring or sub-contracting signature certifies the mellowing. <br /> f this permit is issued, I shall,empl�oy:.persons-Subject;to workman's compensation laws- California." <br /> - i f. a side. <br /> om lete drawing on .r f <br /> The applicant m t c 1 for all 'required insp- ions..,, P Date. 1 <br /> i + ` 4� <br /> Title.: _ <br /> Signed }( L' <br /> FORa DEPAR NT E LY� ea :sL/ � Stk 456-6781 <br /> jApplication-Accepted-byG�/ Lodi 369-3621 <br /> Y '�' } <br /> 4 Additional Comments: , .Date �3`1)L-AManteca 823-7104 <br /> Pit or Grout Inspection b J - "�.�., i Tracy 835-6385 <br /> Date 1 <br /> l <—•.--_, - - L <br /> Final inspection by �C7�sw'� <br /> Applicant - Return' a l copies,Ito:_Env-i•r-onmen.tad.Hea4th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5t k., CR 95201 <br /> DATE PERMIT N0, <br /> I FEE BASE AMOUNT 'DUE AMOUNT REMITTED 6R�ECEIVED BY <br /> INFO l" 0 �O <br /> 10/•8-2 500�j <br /> EH 13-24 REV. 10/82 ` ` ` 0 <br />