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DATE :i511£D d <br /> # �l 1�/ 1 L`11CC3tt! �C� c!?IRES 1 YEn? FRC E _5 <br /> },. ,Ca glete in 7ripiica.el <br /> ! Local Health District for a perait to construct andl,r install the work herein <br /> Application is hercny made to the San Jvaauin <br /> described. This application is c,ade in corsl;ance with San ,;eicuir. County Ordinance No, 549 for sewage or 1;0. 1862 for well/pump <br /> and [#.e Rules�Requlof the Saf Joacuin 'Deni 1t. istrict.Job AddressiefreAddressN UpAtr PhoneOwner's !Same _ i Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP WORK: NEW WELL L WELL REP­CEMENT DESTRUCTION <br /> PUMP INSTALLATION r SYSTEM RE_r"IR l._ OTHER <br /> SMR LINES DISPOSAL FI-D. PROP. LINE. 04 <br /> DISTANCE TO NEAREST: SEPTIC TANK THER '�cLL PITSISUMFS <br /> f — FOUNDATION AGSICULTI.RE WELL O <br /> ' I INTENDED USE - TY,E OF WELL PROBLEM-REA CONSTRUCT[;_SPECIFICATIONS �r< <br /> IJ Industrial U Open Bottom Manteca , <br /> Dia, of Well EXCdeation i! <br /> Diz. Of Well Casing <br /> F-I LbmTracy <br /> �Gravel Pack [{ Y <br /> i <br /> U Other Delta Type of Casing <br /> Public _ <br /> i y h Irrigation — Approx. ❑Eastern Specifications ?e <br /> -D Cathodic Protection <br /> De;th Depth of Grout Seal <br /> D Geophysical Type of Grout <br /> y <br /> U Other Surface Seal Installed by — <br /> 4 p State Wort. Dane <br /> l Revair Hark Done ❑ Type of PUMP — _ <br /> F Well Destruct..G.. U Well Diamet_r Seali^g Material (top 50') <br /> o Fillnr Material ;aelow 50'1 - <br /> Depth ' <br /> e it ermicted if public sewer is <br /> TYFr OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDIT;4i1 J (No septic tank'or seepage p available within 20U feet.) " <br /> installation will serve: Residence Commercial Other <br /> Number of bedrooms l' Lot size <br /> Number of living units: Nater table depth 4O <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> Capacity <br /> SEPTIC TANK Type/Mfg Capacity Method of Disposal " <br /> PKC. TREATMENT PLT. Type/Mfg Foundation r z Property Line ��� <br /> SEWAGE SYSTEM is to nearest: Well <br /> t CESTRUCTION ' Total lengt!s/size <br /> *' t' <br /> S LEACHING LINE <br /> No. L Length of lines .� �_ Property line <br /> L Foundation y <br /> FILTER BED Distance to nearest: Well « _-- <br /> I Size f Number <br /> F SEEPAGE PITS Depth <br /> ` f j•_Foundation r.r_ Property L'r �-- <br /> SUMPS L� Distance to nearest: ',!ell' r- iLSY1-- <br /> DISPOSAL PONDS ED <br /> lication and that the work will be done in accordance with San Jbaauir county <br /> I hereby certify that I have prepared this app _ <br /> ordinances, state laws, and rules and regulations Of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies thesucfOannernzs to becomeysubj,-ct tohworkman�compensatinnwlawsfof California.' <br /> ((( permit is issue), I Shall not employ a y. nature certifies the follow:no: "I Certify that in the performance of the work 'or which <br /> Contractor's ing or sub•^.ontractin _ <br /> i this permit issued, I shall emplo rsens subject to workman's compensation laws of California.' <br /> s. <br /> ' The applic -Lail f all re ed ins ctivns. Comple dra 'n on reverse side. Date: �� � '. <br /> r Title: <br /> ' Signed 7 <br /> FART NT USE ONLY Stk 466-6781 <br /> SyLr c r.v., A ea <br /> Application Accepted by J ^Lodi 369-3621 <br /> f Additional Comments: ?.5 n <br /> u ' - Date V Manteca 923-1104 <br /> Pit or Grout inspection by CL411 racy 635-6385 ; <br /> Date <br /> q 1 Final Inspection by �/. _� 1 <br /> i Applicant - Return all copies to: En vi .mental Heelih Permit/Services ifiL`1 I. Hazel ton Ave., P.Q. Box 2009, St k., CA 95201 tI <br /> •��- 1L+IQUNT REkITTFD RECEIVED SY DATE I PERMIT NO. <br /> FFE BI'.SE AMOUNT OUE Q ff <br /> 10182 50C . <br /> 1 i{ <br /> 10r52 <br /> EH 13-24 REV. . <br /> 1 S 14-�6 <br />