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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Telephone (209) 1- <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> W <br /> g Job s` r .L "` 'dam - CitvA=IVZ7Z5VJ Lot Size PM <br /> N7�•a4 F n-g[�, <br /> Owner's Name Address / �L �/� Phone � �1 <br /> ii10 <br /> Contractor s ��� Addres F7-i6612ItU 12iC+ License No. 7 Phone 6 Z. 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificatins <br /> f'i Public ❑ Other ❑ Delta Depth of Grout Seal Type of` <br /> I I Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by _ <br /> Repair Work Done L1 Type of Pump H.P. State Work Done _ RECEIVi <br /> Well Destruction Well Diameter Sealing Material Itop 501 ill U I n *�3� <br /> Depth 1,„(�/ Filler Material !Below 50'I <br /> VAR. I—AMN <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system p�f�tie�a 7i Lril7vSGr4YICie <br /> available within?t�NR Q�Q�jj�A�II <br /> Installation will serve: Residence— Commercial T -Other MENTAL HEALTH DIVII JON <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth i <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number ' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t i <br /> I hereby certify that I have prepared this application and that the work will be done in accordancg with Sanloaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or.sub-contracting signature <br /> certifies the following: "I certify that in'the performance of the work for which this permit is issued, I shall employ persons subject.to workman's compensa- \ <br /> tion laws of orn' <br /> The appfic t mus 11 fora r nspections. Complete drawing on everse side. W�; <br /> X Title: 4"7 D( ! /� Date: 'Z <br /> (,JET ,,,�rc�/•�7 FOR DEPARTMENT USE ONLY f' <br /> Application Accepted by Date 4 �4 Area <br /> Pit of Grout inspection by �° Date v Final InspaFtion by — <br /> ADt, 7 � <br /> Additional Comments: <br /> Applicant - Return all copies to: Environmental Heplth Permit/Services :P.O. Box 2009, Stk. CA 95201 2,00 <br /> FEE I <br /> bo <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEPD..8Yt7ATE PERMIT NO. �✓ <br /> +.EH1 -241REV.�/r+511AA/] <br /> EH 144 60 <br /> .28 C,,,YYY(({J// VV <br />