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APPLICATION FOR PERMIT / <br /> r *SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Telephone (209) 469'x'1&1 LfA 3y'1 <br /> '1 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 /> Job Address �3Za3 I 'TP11 City Tr4 6 0 Lot Size 1 PM <br /> Owner's Name�t)��Q Ufa l' AddressZOOO Ce-aJ (:-2tV'j 141 OLWO Iw~ Phone '"- <br /> 141r) <br /> Contractor FrlL151CG'1 JGt01 (I Address y'7 L.Gv13L, 'i1 Mi tt� License No.� (r3(a 357 Phone 45W—C)All <br /> TYPE OF WELL/PUMP: NEW WELL`S WELL REPLACEMENT ❑ DESTRUCTION ❑ 11Ctper T'K'Frrtcfi,, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (T <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 21 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 15 .n 40 Fy� Specifications <br /> ❑ Pudic ❑ Other V'1Pa" fl Delta Depth of Grout Seal 5 Type of Grout U rtt+ 6 eiY1 cnt <br /> 1 I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> _ Number of frying units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. fi Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> nubs and regulations of the San Joaquin Local Health District. <br /> Home owner or kcensed agent's signature certifies the following:"I certify that in the performance of the work for which this panni[is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subiect to workmen's compensa- <br /> tion laws of California." <br /> The applicant4nust ce for all req. d mspectioni. Complete drawing on reverse side. <br /> Signed x_ . / ✓/� f' ��v ✓fix Title: 5 7/ %C�l7 Date: /v r <br /> DEPARTMENT USE ONLY O <br /> Application Accepted byV 1 Date Area <br /> Pit or Grout InspectionDate - Final m e'on by Date <br /> an —Kt V- �aX1!2 � <br /> �13 V 7 <br /> Add'ael Comments: <br /> ICI Stk 466-6781 O Lod 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> NFEO AMOUNT DUE AMOUNT REMITTED I CCAKsH RECEIVED BY DATE PERMn'NO. <br /> ..EH 1124 UiEV.rrasr �i ` ii5y ZI �5 <br /> EH 14]e <br />