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(Complete In Triplicate) <br /> APOBCatiort'a herby made to the San Joaquin Local Health District for a permit to construct and/a Install the work herein described.This appypation Is <br /> '''lade al afth DaVi with San Joaquin County Ordinance No.W for sewage or No.18112 for well/pump and the Rules acrd Regulations of the San Joaquin <br /> Local Health Int. <br /> 7 / <br /> Job —� _ City&.{4 f M 0 C� Lnl Sure <br /> _I <br /> Owner's Name�7a e P Address e <br /> n IfL ice---- Phone <br /> COnUactaAddress �� <br /> 0-"-a-C <br /> No.���.j �j_ Phew^' ��•. g <br /> TYPE OF WELL/PUMP: NFvV WE-LL->C— WELL REPLACEMENT f.i DESTRUCTION l 1 i <br /> PUMP INSTALLATION,P�1 SYSTEM REPAIR II OTHER ( 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _J_ SEWER LINES _T DISPOSAL FLD.1_S�'- PROP. LINE - \• <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS \� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS <br /> C3 Industrial XOpen U Manteca T <br /> Dia.of Well Excavation Dia.of Won Casirq <br /> )dDDomestk/Private ❑ Gravel Pack ❑Tracy Type of Casing <br /> 0 Public ❑Other SlwcilMatiats ^ <br /> ���" ❑ Delta Depth of Grout Seal T of Grout <br /> 7 Irrigation -i2"Wox. Depth U Eastern Surface Seal Installed by 71tt <br /> Repair Work Done ❑ Type of Pump uh H.P. ,�_ <br /> State Work Done <br /> Wall Destruction ❑ 'Nell Diameter Sealing Material(top 6(y1 <br /> Dep <br /> Filler Material (Below 5q) - <br /> rYPE OF SEPTIC WORK: NNSTALLA Iq1N Cl REPAIR/ADDITION U DESTRUCTION [ INo wptic system permitted if <br /> available within:00 foot.) <br /> M Irstalletion will so": Raeldertce _ Commercial available <br /> Otla r i <br /> Nun*&or of living units:-_ Number of bedrooms <br /> Character of sal to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg No. Compartments <br /> ?KG. TREATMuJT PLT.❑ • <br /> Method of Disposal <br /> r Distance to nearest: Well FOWA411011`1Property Lino._- <br /> LEACHING LINE ❑ No. b Length of limes -- <br /> FILTER BcD _ Total length/size_- <br /> ❑ Distance to nearest: Well Foundation Property L;- <br /> SEEPAGE PITS ❑ Depth _Size_ --- <br /> Number <br /> SUMPS y <br /> �l Distance to nearest: Well_ Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Moms owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit u issued,I shall not <br /> amploy an A <br /> y person in such manner et to become subject to workman's compensation laws of California,"Contractors hiring or sub-contracting <br /> .:ertifies the following:"I certify that in the performance of the work for which thiss c signature <br /> tion laws o1 California." perm t is issued,I shall employ persons subject to workman's compertsa- <br /> The applicant mm 1 call for�alllrequired inapectnorts�ComPlets­drawing on reverse side. <br /> Signed A,.:( ' n� LCTitle --_-. Date: 24 <br /> FO EPARTMENT USE ONLY <br /> Application Accepted Accepted by Date�_��=�- <br /> Area <br /> Pit a Grout Inspection by Date Final Inspection by 4: � �� DatsE"??�f <br /> Additional Comments: a ��ni�Z✓�ft=� t �.2Y .t�Lcl P. r i�/ fcax� <br /> Stir a58 8781 Cl Lodi 369-3821 ❑ Manteca 823-7 ❑ Tracy 836.6386 <br /> -;•plicant. Return all Copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE „AMOUNT DUE AMOUNT REMITTED K <br /> INFO /w� CASH RECEIVED BY DATE EPERMjIT'NO. <br /> 2`IIrLV r,eo� Oar n 0)J '� , <br /> +•Y•- y <br /> '77M <br />