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APPLICATION FOR PERMIT <br /> Sk N JOAQUIN LOCAL AiALTH 'DISTRICT <br /> AZEr TON C OCKT 'CA": y' ' <br /> 1601E Fi AV 5 C ONK <br /> Telephone <br /> (2091'd66{5181 <br /> PERMIT EX0IRES3j-YEAR Fk6M DATE ISSUED <br /> mpfe5e inTnp}tcate} Yah <br /> Aopficat,ort rs hereby evade is ilia San Joaquin Lpcai Health District for a <br /> perm[ io constiuct andlar install the work herein described:This'appGcatiort is <br /> rnade'in comityli <a with San Joaquin County Ordinance No.549 for sewage or No 188.2 for wall/pump and the Ruins and Regulations of the San Joatiul;I <br /> c- Local Health District. <br /> r _ _ k <br /> n Job Address > P_ Lot Si.e PM. 8- <br /> Ownee Nana Address S..�I Phane y` 1 <br /> Contractors Name License No '.`Y �- x , . <br /> Phone' 'Z <br /> .TYPE OF WELtrPUMP NEW WELL,0 WELL REPLACEMENT <br /> - � DESTRUC 1iON-:❑ r� <br /> PUMP INSTALLATION.❑ ' SYSTEM REr 41R C Y DTHERr7 <br /> 7t . <br /> DISTANCF:TO NEAREST: SEPTIC TANK SEINER LINES 5 ` DISPOSAL FLD. PROP, LiNE <br /> I x _ FCUNDATION -AGRICULTURE WELL_ OTHER WELL - PETS/SUMPS �y <br /> - INTENDED USE `.-TYPE OF WEE' PRD$LEM AREA CQNSTR6GTi4M SPECIFICATIO,V5' ' -- Z • <br /> Industnpf C1 Open Bottom ID Manteca Dia of-Well i xcava:wn Dia of Weil Castn r� <br /> -- a <br /> A- B <br /> 4 t ❑Dorrtestre/Private <br /> Z1 Gravel Pack ❑Tracyy ; i, Type of Cdsing Specifications <br /> G Pudic ❑Other J7 Delta Depth -f Crou Seal Type of Grout T " <br /> Y ❑irrigation _ApMx. Depth '❑Eastem. i Surface Seal Installed by <br /> % Repair Work Done 0: Type of Pump 'H P � � State Wvrrc Dane <br /> ' Welt Destruction ❑ We.i Diameter ' r <br /> r Seating HTaterwl{top 5JY) <br /> Oapth Fittar Matenat[Below 50} <br /> t Y <br /> TYPE OF SEPTIC WORK NEW tNSTAi_LATION L3 REPAIR DESTRUCTI()N C) INo septic system permitted if public sewer is. <br /> � t <br /> available within 20o eat 1id <br /> a� <br /> Erxt•3ltation will serve Resdence�,' CorrrM C':al Other t s$r <br /> lumber of Going units / Number of <br /> Chsiat.ter.of sod to a depth of 3 feet ��� `'�f s luster table depth 5 <br /> SEPTIC TANK '_- ❑ .Type/Mf <br /> a <br /> 9 Gapauty _ No. Comparfmants _ �k <br /> PKG.TREATMENT PLT Cl Method of Disposal <br /> t]istanca to nearest Well Foundauan Property Une t <br /> LEACHfNG.LINE 'No.$ Length of lines _Total rength/size <br /> { FILTER SED ❑ Distance to nearest. We:. oundatian Property Line <br /> SEEPAGE PITS ❑' Depth Sue "_ Number <br /> SUMPS ry Q ` 0,tanre to nea est:" Welt` Faundation Pro s <br /> 'i party Line <br /> DISPOSAL'PON!}S. ❑ <br /> r{ .I hereby certiN.that i have prepared this application and filet the work will be dorie�in accordence with San Joaquin county orrtinances,state lawn and <br /> w ' ruses and rcgulstiore of the Sart Joaquin Local Health Dlsuiet: <br /> Homo owner or 1leertaed dgenlI signature certifies the following 'f,certify that In the.performance of the work for which this permit is issued,l shdfl not <br /> i employ any person In such manner as to became su1I to workman's compensation Jaws of California."Contractors hiring or"sub-contracting slgnature r <br /> certifies the following."F certify that in the peHorm„nce of the work for which this permit is issued,I shall employ persona IItibject to workman's compenaa a r <br /> M r tion laws of California:' <br /> t The appircera t II for all r-Mil i is Cornpiete drawing on reverse side _ t _ <br /> Signed X' Title. r,. <br /> i <br /> FOR DEPAR ENT USE ONLY <br /> F AWKaaon Accepted by <br /> .. _ i:; <br /> Pit or Grow:Inspection by � Da'S Fnai Inspcctian by Date <br /> Addit;Cinal Cori ments: / r <br /> ❑Stk 466-Ml G Leci 3W31MI ❑ Manteca 823-7504 Cl Tmcy 8356385 <br /> Applicant-Return an c*pi"to:Emirrnmental Health Permit/Services Moll E.,Haznitan Ave., P.O.Box 2009, Stk., CA 91 <br /> INFO AMOt1NT DUE AS CrUNT RMITTED H R$CLEYED BY DATE PERMIT'NO.FEE ' <br /> - '..F?I:z7srRFJ.rOrt>' . �L.— <br /> WM. <br /> !"I'f. <br />