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. ei� JTT t.lPlfl{�S r .'fA11 P}rplRIIA'c� �554�t7 <br /> (Complete in Triplicate) <br /> App Kation •s hsroby made to the Sari Joaquin Local Heatth District for a permit to eanstruct andi or install the work herein described. This application is <br /> rnade in compliance with San Joaquin Cc my Ordinance No.549 far sewage or No. IM for well?pump and the Rules and Regulations of the San Joaquin <br /> Local Health Distr,ct 75 b f. C[wo Sift- <br /> Jab ACdress ir <br /> City A061 JA t Size PM <br /> Owner's Name �✓'J L5 Address �L Wi s _s. / p/lg "m Phone —V---0J?14 <br /> Contractor _ Address _icense Yo" Phone <br /> TYPE OF WELL;PUMP NEW WELL O WELL REPLACEMENT f_i DESTRUCTION D <br /> I PUMP INSTALLATION L1 SYSTEM REPAIR 0 OTHER J <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLb PROP. LINE <br /> i FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIORS <br /> 0 Industrial _ Open Bottom Ct Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private D Gravel Pack L Tracy Typo of Casing _ Specifications <br /> C Public ! Other C Delia Depth of Grout Seal Type of Grout_ .. <br /> ] Irrigati ton _,-Approx Doom C Easiorn Surface Seat Installed by <br /> Repa,r W4rK Dane Type of Pump H.P _ State Work Done <br /> We1 Destruct+on Wel D ameter Sealing Matenal Itop 501 <br /> I booth ---- _. rdlar Material (Below 50") <br /> -VPE OF SEPTIC WORK NEW ;NSTALLATION I "`REPAIR/ADDITION I I DESTRUCTION C INo sept;c system permitte(s if public sewer is <br /> 1 <br /> y available w thin 700 reet I <br /> �\ <br /> insla'lation wi'l Serve Rea f/ao'ico -_ Commercial_ Other <br /> Numbtir e' ling unas: f _ Number of bedrooms. -- <br /> Cnararter of soft to a depth of 3 feet: � �lj�f7" Water table depth <br /> SEPTIC TANK L.,�ype%Mfg Capacity IgRQQ. No. Compartr-mnts 2- v <br /> aKG- TREATMEh- PLT Method o' Disosal _ <br /> Cms} Distance to nearest: Well . - _`' -- , roundation - �� Property Line <br /> LEACHING LINE No. S I en th of linos r <br /> 9 t �.__. _ Total length?size ` <br /> rILTER BED _. f D stance to nearest Well OS Foundation _ /� Property Line S l <br /> r <br /> SEEPAGE PITS - Depth _Sire Number ` <br /> SUMPS Distance to nearest: Well _-_- _ Foundation Praperty Line <br /> DISPOSAL PONDS <br /> I hereby cer dy that I crave prepared this apOxaMr. and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regOatiors of the Sar Joaquin Loca: Heahh District. ; r .! <br /> Horne owner or licensed agent's s gnature cartifies the following:_'I certify that in the performance of the work for which this permit -s issuers, I shall not <br /> employ any person in such manner as to becomoo sa*p cl to workman's compensation laws of California. Contractors hiring or sub-contracting signature <br /> cortif;PA the fokow.np• "'i ce,liry that r the performance of Ilia work for whrch this permit is issued. I shall employ persons subject to workman's compensa <br /> tion laws of Ca' rnw.- <br /> The appl-can ust ca I for ail r 9 red mspechons. Complete drawing on reverse side. <br /> Signed Title. Data: . <br /> OR DEPARTMENT USE ONLY <br /> Application. Accepted � Area <br /> Pit or Grout Inspection by Date Final Inspection Date -5~8G <br /> I <br /> Additional Comments <br /> Oak S11.9211.1 n r.s <br />