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iPERMIT N0. <br /> Tele.,hone <br /> DATE ISSUE;-s <br /> PLP`:- _vP!P,ES 1 YEAR FRO^S <br /> a-rolete in silica <br /> Application is hereby made to the San Joaquin vocal Health District for a permit to construct and!ar install the work herein <br /> described. This application is made in Cx sliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Reyulations of theSan oacuin Local Health District. <br /> Job Address /2Zf37 Suhdiv-,,ion Name <br /> Owner's Name c%/ Address <br /> _ Phone <br /> Contractor's Name License No, Phone <br /> TYPE OF 'JELL/PUMP WORK: NEW WELL 14ELL REFL„CEMENT L-1 JESTRUCTION [es <br /> PUMP INSTALLATION SYSTEM REPAIR, OTHER f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A^ DISPOSAL FLD. PROP, LINE <br /> FOJNDATICN AGRI'JLTJRE WELL OTPER L!. PITS/SUMPS <br /> INTENDED USE TY^E OF 'WELL --POBLEM F,RLk ONSiRJCTI^,^! S: FCIFICATIiNs <br /> I Industrial Open Bottom <br /> �( p I ' Manteca Dia. of Well Excavation <br /> L} Domestic/Private Gravel lack Tracy Cia, of Well Casing <br /> 1-1 Public J Other 7, Dei to <br /> irrigation ry e of Casing _ <br /> L 9 _ Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> ilGeophysica] <br /> Depth of Grout Seal <br /> Other <br /> Tyre of Grout <br /> .� <br /> Surface Seal Installed by C 1 <br /> Repair Work Dane Type of Pump H.P. _ State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION F� (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial _ Other available within 200 feet.} <br /> Number of living units: I Number of bedrooms �. Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg CV",::- ,� ,y Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation --? Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines 2� 'Y 7 <br /> g � � Total length/size <br /> FILTER BED U Distance to nearest: Well IeVg � /�Four,daticn ��� Property Line <br /> Al _ <br /> SEEPAGE PITSDepth Size �3 Number _ <br /> SUMPS Distance to nearest: ideII F_oundaticn Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the followinq: "I certify that in the performance of the work for which this <br /> Permit is issued, I shall not employ any person in such manner as to become subject to workmanK compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the aoliowing: "I certify that in the performance of the work `or which <br /> this permit is issued, I shall employ persons subject to workman's conpensation laws of California." <br /> The applicant must call fo all r ired inspections. Cemplete drawl n reverse side. <br /> Signed X Title: /yJ D!"_�—_ Date: <br /> IF EPARTh T USE ONLY <br /> Application Accepted by Area 1 Stk 466-6781 <br /> Additional Comments: �iKLodi 369-3621 <br /> Pit or Grout Inspection by Date L-1 Manteca 823-7104 <br /> Final Inspection by Wil(_ Date �; EJ Tracy &356385 <br /> Applicant Return all copies o: n ronmental Health Hermit/Services 1501 E. a elton Ave., P.O. Box 2009, St k., CA 95203 <br /> FEE BASE A'�1CUNT DUE Ai10UNT RE,'''i"T C"T C RECE_1+DED BY DATE PERMIT '�O, <br /> iNFG <br /> �s <br /> EH 13-24 REV. 10/82 10/ � 500 <br /> 14-26 <br />