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-,SSV-E.P <br /> MSS! <br /> lth PiStri,-1 for a :errlit 1,0 C0ns-,u,-' j.nd!flr install the work herein <br /> t maef. *,D the ',-Im �04(W'n Local ounr <br /> dt"(—hr-,J. ihiS ap')-I icat ion is wale in Cor:>l jan[f.1 with Sam J'AqUin ',QUOtY Oralw(c qo. •1'� (cr %eWAQ0 or of we <br /> an 011VU !i�,altwlvo <br /> and 'ho tuIPS Lind P-?(julatiorl, th(' 5 49 /.W-1 <br /> Jot, Add WI I V I I oll r Phone <br /> 70% <br /> lit_ <br /> 'a* <br /> W r <br /> —CrAj i I <br /> I Phone <br /> e No. <br /> C�Intrdctor's Nano <br /> WELL REPTACEMEN, OESIRUCTION <br /> TYPE O�WLt�/PU I WORK: NEW WELL 91 Z <br /> PUMP INSTALLATION SYSTEMPIPAIP U OTHL" <br /> 00, )P. LINE 10 <br /> SEWER LINES DISPOSAk- FLO. PR( — <br /> DISTANCE TO NEAREST: SEPT;C TANK rouNDATIAGRICULTUP1 WELL pl[pep WLt- r I <br /> TS I SS" <br /> INIE'41a' "SETY7[ OF ',iELL PROBLEM APE,' SPECII--ICAT1,1?6 to <br /> Kopcn Ebttom Manteca ni&, of tiell <br /> EKcaGravel rackI Tracy Dia. of 4p <br /> Public Otj-,trrj Delta jype if Cosinq <br /> irrigation Aop $ppc I I IcAt 1001 4 <br /> Cathodic Protection <br /> Depth 5-lith of Grout Sea <br /> 7yoc of Grout <br /> Surf6ce Seat Enstelied by <br /> Irr P^Pair Work Done El Type of Pump State Work )one <br /> Noll Destructioo [j Well Diameter Sealing Material (top 50') <br /> Depth filler Material (Below W) <br /> mitted if public fewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ([lo septic tank or seepage Pit"Pey <br /> a ailable within 200 feet.) <br /> Installation will serve: Residence Commercial other <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Charafter of soil to a depth of 3 feet: <br /> cAracitv No- Comaartrents <br /> SEPTIC TANK I Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg Property Line <br /> SEWAGE SYSTEM . Distance to nearest: Well Foundation <br /> DE57RUCTION <br /> Total lrn0t'T1size <br /> Cj- No. & Length of lines <br /> LEACHING LINE Foundation Property Line <br /> FILTER BED Distance to nearest:. Well <br /> Depth <br /> Iumber_ Size <br /> SEEPAGE PITS Distance to nearest! .Well round;it jor _-- llrojirrty Line <br /> SUMPS <br /> DISPOSAL PONDS <br /> I "reky certify that I have prepared this dVPIiCB I'on and that the work will be done in accordance with Sam Joaquin county <br /> ordinances, State laws. and rules and reg�jlations of the San inAiuin Local Health Oistrtct- the work for which ttlis <br /> the lolinwing: ,I certify that in the performance of California." <br /> Home owner or licensed agent's signature certifies to become subject to worksmn�colmoef'-100' 1-1ws mf 4"Ir w1rich <br /> I I h 11 not @mploy a,.Iy peirson in such manner as . rrance of the Wnrk , <br /> ermit is issued., a certifies the. follownu: i,j certify th,,.t in the'pey'170 <br /> Contractor's hiring or sub-Contractinq signature -PensAt"m laws of (al.,form iA, <br /> JAL <br /> this permit IS issued. I shall empiny persons subJect to wr)rkmn's cCmr 4de <br /> Complete draw'iQQ--01revrse,&# <br /> D <br /> applicant <br /> T applicant <br /> he ate: <br /> Slg�ned X <br /> RTMENT USE tX-V Area Stk 466-6781 <br /> Application Accepted by Lodi 169-3621 <br /> Application Accepted by <br /> fr Additional Comments: ganteca 923-7104 <br /> Pit or Grout lnsPectiOR-hyr Tracy 05-6365 <br /> Cla t e ---4, ac <br /> �71 —1 Stk., CA 95201 <br /> Final InspeCtiOil by : - tGffvr,., P.O. Snv 2009. <br /> lth Permnit/Scrvices 101 C. ON--el <br /> r-1 1 CS?�t Environmental H <br /> Applicant Return all <br /> Rr-.ETVEP B"+ DATE <br /> PcfM1T NR. <br /> 0,,NT Disc AMOUNT RE�'!TTZO <br /> FEE I BASE <br /> F LH 13-24 REV. 1018i <br /> 1.1-26 <br />