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l ❑ Domestic/Private ^ Gravel Pack [J Tracy Aia. of Well Casing <br /> 0 Public ❑ Other Delta ,ype of Casing <br /> Lj irrigation Approx. Eastern Specifications <br /> Cathodic Protection <br /> .... ❑ Depth Depth of Grout Seal <br /> LE)Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> ti 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 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION F) (No septic tank or seepage pit permitted if public <br /> available within 200 <br /> Installation will serve: Residence *K Commercial _ Other <br /> Number of living units: _1 Number of bedrooms `�_ Lot size <br /> Character of soil to a depth of 3 feet: 0o �p �. Water table depth A <br /> SEPTIC TANK Type/Mfg 4A j.at3Pacity _ No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> - <br /> SEWAGE SYSTEM Distance to nearest: Well � _ Foundation .� Property Line X7,0 <br /> DESTRUCTION O <br /> LEACHING LINE No. & Length of lines S 2 O Total length/size <br /> o- FILTER BED L] Distance to nearest: Well oundation ,Z0 Property Line Sd <br /> SEEPAGE PITS [) Depth Size Number <br /> SUMPS (J Distance to nearest: Well Foundation Property Line <br /> '— DISPOSAL PONDS CI 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui <br /> ordinances, state laws, and rules and regulations of the San JoAuin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fa <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws a <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the <br /> this permit i issued, I shall employ p ns subject to workm 's compensation laws of California."- <br /> The applic call for 1 requi insp4Wtions. Complete raw n reverse side. <br /> Signed X Title: Date: . <br /> O P Tj4ENT U E N ❑ <br /> ` Application Accepted by ea Sok 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by /a/I� Date /�/ 1"d f L7 Tracy 9, Stk8, <br /> Applicant - Return all copies to: EnvirA/ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., <br /> FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />