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<br /> `�` APPLICATION FOR PERMIT :
<br /> SAN .IOAaUIN LOCM. HEALTH DISTRICT
<br /> Ifi01 E ;HAZE:,TON A1/ :aSCiC4TON,
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<br /> ;, �'rERMIT EXPIRES 1 Y>+ARbATL� 1SSt ED `mak , F a i,k t � r '.
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<br /> ' Application tri helsby mage to:the Safi Jo eith � � y
<br /> made in compliance with San Joaquin County Ordinance No�549 f .tsewe N8 1862 fgtjrgelf/pump and the Ru'lar�i v the 8 Irt
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<br /> =:;Local Health Distract. j �P '�S '„
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<br /> Job AddressEl
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<br /> DVwter�a Name
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<br /> I ;: License"N6."Contra01 ess . y Phone
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<br /> E OF WELL'/PUMP: klfEEf� v ��i. WELL REPLACEMENT'
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<br /> t " PUMP IN�TALLTION ❑ SYSTEM REP
<br /> / DISTANCE TO NEAREST :SEPTIA _q' DISPOSAL FLD w ^,;PROf' INt;
<br /> _ =5iFOUNDA'#'IOiJs ;. . : AGRIC E WELL: OTHER WELL, '',PITS/SUMPS,
<br /> 1NT DED USE - ', `OF Wf`LL t r R AREA CONSTRUCTION=.SPECIFICi4TfON$
<br /> y w:- x .a eP S3�tro r$ arA b :k ri
<br /> ' 'C]}Industnal fO Qpen Bottom Manteca + , Ola:•of Well Excavation f I}ia BII Casing
<br /> Ff a. i i .. i s w. r- ='- e +?:, -1 ;-.w. A:; --. S _-;��, -x� .,� .� ,+. r �I v r -, r q _
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<br /> f r3lborrlesnc/Prorate3 Gravei Pa -� ;Tracy > x Type of,Cesing �����{{+ 1 G
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<br /> g�tl Frrg two pprox:Depth i i 1:IEastem it 4 Surface Seal Installed byr i �e "`
<br /> Repai.'WOrk Done z❑ "'fype'o Pomp y xn ryW a# Cfs�_ :x r _ tate 1�i�r)rl(jDW1a
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<br /> t �iif 1.i;}gatrucsion� C�" Weil Dla "ter" SeaCmg�Materlal lto 5fr�7 t�° ��
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<br /> Depth } Iler;N�aterial
<br /> c" p TYPE OF SEPTIC WORK NEW INSTALtA'TiON f 3 YR IRYADDtTION i I pE RUCTION 1No septic spermitted If publid sewer Is
<br /> F `" �rt�� \ ; r .#► s, actable w+ I 200 feet.}
<br /> Installation -¢-.-
<br /> wilt serve: Residence Commercial tFier } i
<br /> Number of livin ' nits. Number of bedrooms,.
<br /> Character ofs 11 to depth•of 3leet r or table depth j
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<br /> SEPTIC TANK ❑ Type/ ` Cape No.'Compartmenta
<br /> PKG. TREA. EN LT ❑J, Method of Disposal
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<br /> Distance to nearest: Well F tion Property,Line
<br /> LEACHING IN No. of nes Total length/size
<br /> FtL 'B to a to nea t: Well Foundation Property,'Line
<br /> SEEPAGE PITS i B Depth Size Number
<br /> SUMPS T; q.Ll Distance to nearest: Well Foundation Property Line
<br /> DISPOSAL PONDS C] J
<br /> I hereby certify that I have prepared this application-and Arthe work will be done in accordance with San:Joaquin 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.follcwing: "I:pertify.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 workmari:s compensation laws of California."Contractors hiring'or sub-contracting signature a
<br /> certifies the following:'9.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 California," _ .
<br /> The 00cant t call jor all r uireeQ-Ar^fs . Coompl to drawing on rev side_ 7j � 1
<br /> Signed X "� �� /I,_ .�G title: � - i Date:
<br /> „�3A<ATlNUSE ONLYr r ;`
<br /> Application Accepted by ` -.D Area t
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<br /> Pit or Grout Inspection by Data Final Inspection by - Date
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<br /> Additional Comments
<br /> R FC},-Stk 466-fj78f r{� 0 Lodi 3 3G2t " ❑ Ma_rltecs=.s8?3 71644 0 T►acy ;835-6385
<br /> 2- Applicant Returns-all=i�ples to Errvltonrtterttal:Health Psrmit/Services 160f E Hazelton Ave, P.O, Box YON,',Stk.;,;CA 66201 H
<br /> FEE OUNT DUE,- /1MgUrIT REMITTED gECEIV PERMIT'NO p
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