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f <br /> APPLICATION FOR PERMIT <br /> a . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> cation is <br /> r install the work <br /> Application is compliance with San Joaqu nnCounguin Local Health District for a ty Ordinance No.549 for sewage or permit <br /> Noo. 1862 forcwell/dpuomp and the Rules and 1Regusations of the San l J agiiin <br /> made in comp �� <br /> Local Health District. <br /> Cam Rd city <br /> Manteca Lot Size +40 acres PM <br /> Job Address 2771 E.: French <br /> Owner's Name Ace Tomato Address <br /> SaiRe Phone <br /> 3 5 6 0 Phone <br /> Contractor Clark Well Address 2024 E. Charter LicenseNo._ 71�— <br /> TYPE OF WELLIPUMP: I� NEW WELL ❑ WELL REPLACEMENT} DESTRUCTION D <br /> PUMP INSTALLATIObUN <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPITIC TAN SEWER OTHER WE r PITS/SUMPS <br /> F01'NDATION AGRICULTURE WELL — — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n <br /> X ldustrial ❑ Oipen Bottom XR*Ianteca Dia. of Well Excavation <br />€ Type of Casing Specifications .250 <br /> a DomesticlPrivate XRXGravel Pack ❑ Tracy } Type of Grout—O <br /> f 1 Public ❑ Other ❑ Delta Depth of Grout Seal - <br /> I I Irrigation �I_Approx. Depth 1 I Eastern Surface Seal installed by <br /> H.P. State Work Done <br /> Repair Work Done L7 Type of Pump �p <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth '1 <br /> Filler Materiai {Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I aNailabpelwwithin 200 feec system t.) if public sewer is <br /> IIS <br /> Installation will serve: Resi ence— Commercial— Other <br /> Number of living units: ISI Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth!f of 3 feet: No. Compartments <br /> SEPTIC TANK El 'TypelMfg Capacity <br /> Method of Disposal � <br /> PKG. TREATMENT PLT.❑ <br /> :;Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ INo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITSI I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line `1 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have p4pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C fornia." 1! <br /> Tfia applica us c I fired s ctions. Complete drawing on reverse side. �] <br /> Title: ITP rl ark Wel I Date: _ �} <br /> Signed X <br /> F. DEPARTMENT USE ONLY <br /> S' Area <br /> Application Accepted by Date �.� <br /> Pit or Grout Inspection by <br /> �l Date �r Final Inspection y Date <br /> Additional Comments: ill <br /> El Stk 466-6781 ❑ E'od i 369-3621 CIManteca 823-7104 L2Tracy 835-6385 <br /> Applicant Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 <br /> FEE FOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT�NO. <br /> a-EH 53-241REV,iiKsl INFO lour�� - <br /> EH 14-26 8 U5 <br />