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i CLARENCE'S SEPTIC & SEWER SERVICE APPLICATION FOR PERMIT 263 So. Oro � Stockton, Calif. 95205 C1ARE tCc'S SEPTIC & SC,'JE;t SERVICE. Ph.463-3209 Contractor's Lii,. , Calif. 95205, SAN JOAQU'I; LOCAL HEALTH -DISTRICT �26717.� 263 so, Oro � StOCacto, Ji 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO, Ph.rs63-6209 GOOtI2CtOr'S(iC. �2g717: Telephone (209) 466-6781 r DATE ISSUED1V t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S (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. 544 for sewage or No. 1862 for well/pump } and the Rules and Regulations of the San Joaquin Local Health District. oQ ' Job Address Subdivision Na e eii ' �/�rey Owner's Name , � Address `�c� Phone Sri/ Contractor's Name License No. a J —717, Phone ilr TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION I❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ? J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I J Industrial U Open Bottom 71 Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing I I] Public ❑ Other Delta Type of Casing Li Irrigation Approx. Eastern ❑ Depth Specifications l Cathodic Protection p Depth of Grout Seal Geophysical Other Type of Grout ❑ Surface Seal Installed by U[ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter . Sealing Material.(top 50') _ Q Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal 110_ SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ° No. & Length of lines Total length/size a ` FILTER BED Distance to nearest: Well, F E — SEEPAGE PITS �' Depth „� r-- Size ' Number SUMPS Distance to nearest: Well. Foundation l� / Property Line_ DISPOSAL PONDS CI lAmle /am."r 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 r qu' ed insp tions. Complete drawing on ers s'de. Signed X Title: Date: ORNT USE ONLY Application Accepted by Area 02— � Stk 466-678 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823--7104 Final Inspection by Date L lG w Y3 L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk„ CA 95201 j FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO 1 EH 13-24 REV. 10/82 10/82 504 14-26 I