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Application is hereby •ade to !•e San r0 i..:.•r -9cal a :er+t to construct 3re'or install the work her?in described bed. This applicatior- is -ace i ce `c• - +..' :r�i-ance 'to. 549 `cr sewage or No. 1862 for"elllouiro and the Ruies ark Regulations o` :^+ .a^ 'n-3 -_•3,!• Job Address7(rzZ—�✓A7Fp. .u. owner's lame ��}j( LzJGGHCTTj Address C'E 1;7Phone _ ZinLl1a L Contractor's Name P� �.�fl/\/s L+cen:,e ••o. '?Sa} 3�}� Phone r f TYPE OF ABET/PUXa AOR! W---L — aEu CES--:C•ION L y ru; -- ,•-5'—LLATIrry .— 5':v GTHER f _ - -- DISTANCE TO NEAREST: SEPTIC '.'.! S_�ro �:'•:: =CSAL FEC.' PROP. LINE FOL'•,,. :Cti PTTS/SIMPS -- 1 INTE',CED USE + OF :U• __r_E; V:S"Rt" __-_ _--- J industrial U Open Potton •'a^Leta Dia. or _ v V Domestic;arivate M 5ravel Pack L_Tracy iia. c` well Casir,g _— 1 i]Public Other Celta a lJ U Ty.e d` Casing __--- i� Irrigation Approx. ✓J Ea;tern C Depth Specifications Cathodic Protcction _JOeatn of Grout Seal Geophysical l 'yoe o` Grout J Otnt•r - -— Sarface Seal Installed b. Repair Work Done❑ Type of Pump ".c. — State Wcrk Done ---------- well ___ _-_well Destruction❑ Well Diameter -_ Sealing :aterial (top 50') }• Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L.' REPAIR];.D3IT:O.'4 X i'e3 septic tar.i,. or seepage pit permitte6 if public sewer is available within 200 feet.) _1 Installation will serve: Residents Commercial _ Other Number of living units: _/ Number of bedroons �_Lot size Character of soil tr a depth of 3 feet: i-7.iX�B� Water table depth �O Cr SEPTIC TANK (_ Type/Mfg _ Capacity _ No. Compartments `J PKG. TREATMENT PLT. ❑ Type/Mfg --_ capacity Method of D-;posal a SEWAGE SYSTEM F, Distance to nearest: Well —__ Fourdation _ Property tlne - "" DESTRUCTIGN LEACHING LINE lip. 4 Length of lines �_� ___. iength/Size t FILTER BED �—1 Distance to nearest: wall -/lA Fourca!tan S/� Property line r + SEEPA&E PITS Depth -- r Size — Z �— 'cumber -- — , 1 SUMPS L I Distance to nearest: well ` roun:a- or �� Property Line /12 DISPOSAL PONDS CI i i hereby certify that I have prepared this application and that the weri. w•I1 be done in accor•:ance with San Joaquin county ordinances, state laws, and rules and reguiations of the San Joaquin Loc+l He,-!o District. + Home owner or licensed agent's signature certifie, the `oilowina: '! certi`y that in the Perf„mance of the work for which this ! permit is issue 1 shall not employ any person in such canner as to orcome subj-ct to worsmank compensation laws of California." Contractor'S h' ing or sub-contractin: , anature cfrtifies the folipw•nn: "I certify that in the pertormance of the work roe which • this pe r^lt 1 i Stied, I Sh 11 e-;!`. •- sons suvjtit LO wor!"dn'S CO�;ensation laws o` California." The aDpli s. . 11 f all r u ria in�tions. Co-p1e• dr on reverse side. r Q "• Signed -- — Title: _ � � Date: Z qqF IT USE ONL, Application Accepted Dy — �n —_ Area �'v Stk 466-6781 Additional comments: _ J Lodi 369-3621 Pit or Grout Inspection by __ Date L; Manteca 823-7104 3 Final inspection byo "r _ Date LI Tracy 835-6385 ! Applicant - Return all copies to: Environmertal Health :ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; rEE BASE ..".;GIT DjE - M^U',T PE>:"ED—r— FELE'<'rED 8r I DATE PEPM;T NO. 1»•-- a,