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` APPLICATION.FflR PERMIT <br /> SAN JOAQUiN�,L GAC HEALTH OI TRICT <br /> k 1601 E. HAZELTON AVE., STOC, '. ' <br /> Telephone (209) 466-6..' PERMIT NO. <br /> PERMIT EXPIRES 1 YEARFROM��TE ISSUED DATE ISSUED <br /> 1 <br /> (Complete inTrj.q'.,F <br /> t �-fi�icate) 4 <br /> "Applicetion``i"�^hr�' made to the San Joaquin Local v <br /> € described. This applica[o °�:,�.�? .' �pliance with SanDJoaquct for d in County perillit to 0 Ordinance No. 549tfordsewagesorlNoth1862rforewell/pump 1 C11 <br /> f and the Rules and Regulations o �he San Joaquin Lj. al ealth District. <br /> Job Address ��. r I <br /> Subdivision Name D <br /> 00 <br /> Owner's Name t ., Address . _ <br /> Contractor's Name • - Phone s' -0 <br /> 1 License Na. 1 Phane �� <br /> B _ <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER jL <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLU, PROP. LINE <br /> FOUNDATION 'I AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Manteca Open'Bottom <br /> ❑ Dia, of Well Excavation <br /> F-1 Domestic/Private •❑Gravel Pack Trac <br /> L Public i Y Dia, of Well Casing <br /> ❑ Other. Delta <br /> LjIrrigation }" ❑ Type of Casing <br /> Approx.A < � Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> _S�Iurface Seal Installed by a <br /> Repair Work Done ❑ Type of PumpH.P, State Work Done �.► <br /> i <br /> Wel 1 Destruction U Well Diameterl Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION }L (No septic tank or eepage pit permitted if public sewer is ' <br /> ,,available within 200 feet.) .� <br /> Installation will serve: <br /> Residence r Commercial Other � c <br /> Number of living units: Number of bedrooms <br /> * Lot size <br /> Character of soil to a depth of 3�.feet: (� <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg d <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Ca acif" <br /> P Y Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation f <br /> DESTRUCTION Property Line ,F <br /> LEACHING LINE ❑ No. & Length of lines { I' <br /> Total length/size <br /> FILTER BED ❑ Distance,jo nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> ISPS <br /> DPOSRL PONDS L Distance.to nearest: Well Foundation Property Line <br /> ISLj <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 ss ed, I shall <br /> agent's signature certifies the following: "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 workman compensation Taws of California." <br /> Contractor's hiring or sub-contracting Signa re certifies the following; "I certify that in the performance of the work for which R <br /> this permit ssued, I shall employ per subject to workman's compensation laws of California." <br /> i <br /> The applic6� c 1 for 1 requir i pectin Complet -dr n reverse side. <br /> Signed ' Title: Date: �'� <br /> FO EPARTMENT USE DNLY <br /> Application Accepted by _7", Area ��� Stk 466-6781 # <br /> h ,,Additional Comments: `1. ❑ Lodi 369-3621 <br /> R_i_ Cut_inspect <br /> ion � <br /> Dates ❑ Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385Applicant - Return all copiHealth Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUEJ _ AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT N0. <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 E <br />