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FOUNDAHUry ,._" <br /> IE OF WELL PROBLEM AREA r•nNSTRUCT10N SPECIFICATIONS Dia. of Well Casir <br /> INTENDED, USE ❑ Manteca Dia. of W1 :cavation�----- <br /> ❑ Upon Bottom Specilications.— <br /> n Industrial Type of Casing_ <br /> ❑ Gravel Pack ❑ Tracy Type of Grout <br /> C7 Domestic/Private n Delta Depth of Grout Seal <br /> I'I Public I:1 Other <br /> Surface Seal installed by <br /> I I IrriUation _.Approx. Depth I I Eastern State WorkDp <br /> of Pump ,e 3 <br /> H.P. 3 <br /> Repair Work Done ❑ Type Sealing Material 3 Depth plrli'� �� <br /> Well Destruction ❑ Well Diameter <br /> Filler Materiel a Depth <br /> Depth <br /> available within 200 leet.l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo septic system permined i <br /> Installation will serve: Residence — Commercial Commercial _ Other -' <br /> Number of living units: — <br /> Number of bedrooms Water table depth <br /> Character of wil to a depth of 3 feet: Capacity No. Compartments — <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size_,.--------- <br /> LEACHING LINE Ll No. 6 Length of lines property Line <br /> FILTER BED CI Distance to nearest: Well <br /> Foundation <br /> Sire __----- Number <br /> SEEPAGE PITS if Depth Property Line <br /> SUMPS LI Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county or inan <br /> rules and regulations of the San Joaquin County certg „ <br /> Home owner oliven such manner as signature cenifies <br /> subject the following: <br /> wing: "I 's clompensation lawsoof California." Contractor'swork for )hiring or sub-1 <br /> employ any person <br /> empl y the following: u certify that in the performance of the work for which this permit is issued, I shall employ persons subject to w <br /> tion laws of California." <br /> Theapplica Ust call required inspections. Complete drawing on reverse side. <br /> Title: <br /> ((�Jr n . . �A >D h Date: <br /> Signed X <br /> �j R DEPARTMENT USE ONLY <br /> \� � � Date 8 Z Prea _ <br /> Application Accepted by A) - — <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: EevironmentaloHealth unty UPermit/Services <br /> blic Health vices <br /> 445 N San Joaquin, p O Box 2009, Stirs, CA 95201 <br /> _ CK RECEIVED By DATE PER1, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH Iy211REV.1)") �.�'p <br /> EH 14-26 <br />