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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> Telephone�(24;8� "i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applican is <br /> all the work <br /> n describe . This <br /> cation is <br /> made ntrcoompliiance writh Sano <br /> oJoaquin Cou Qty Ordinathe San Joauin lnce No. 549 for sewage or Health District for a permit <br /> 1862 for cwell/dpump and the Rules and rRegulations of the San l Joaquin <br /> Local Health District. WICK <br /> City Lot Size PM <br /> lAddress ( /` �•� '�L , 1 f"►��4 / Phone 7 <br /> Owner's Name <br /> x lt <br /> /� T ��1 C,� ��G� C. License No. -Phone b <br /> Contractor AddresS <br /> ( Z " 6 <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecificat�ns <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP O n <br /> ❑ Delta Depth of Grout Seal Type of <br /> ('1 Public Cl Other _ <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Iv <br /> Repair Work Done Ll Type of Pum p H.P. State Work Done _ <br /> T x111 I A + +g92 <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth / Filler Material (Below 501 CJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i 1 iNailab septic <br /> system UUffVV�At [ lA JCINICE <br /> Ctv MENTAL HEAL'H DIVI ION <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms _ <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Ca <br /> SEPTIC TANK ❑ Type/Mfg <br /> pacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth <br /> Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line F <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the 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 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 osignat re \ <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perso bj D <br /> sa- <br /> tion laws of orn x' <br /> 4 <br /> The applic t mus all for all r nspections. Complete drawing;oneverse side. Z e <br /> Signed X <br /> Title: it-O�'t�: 17��."�C(�/S ate: <br /> �T-_Iro ^ FOR DEPARTMENT USE ONLY <br /> Date Area <br /> �/� � <br /> Application Accepted by (� �'G� / <br /> G � c �v <br /> Pit or Grout Inspection by �� Date Final InspeFtion✓b1y Date <br /> -30 '4115 <br /> Additional Comments: ' <br /> ., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Heplth Permit/Services � 1 <br /> FEECK 4 RECEIVE BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13.24(REV.I'H51 <br /> EH 11-28 <br />