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FOUNDATION RJ ' AGRICULTURE WELL Ifh[gr= U Httt wtLL LNu nio w. <br /> INTENDED USE 'YPE OF WELL PROBLEM AREA CON5T'�7TION SPECIFICATIONS <br /> '� ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatito�n_ S °r Dia. of Well C <br /> Cl Domestic/Private ❑ Gravel Pack 'D4,Tracy Type of Casing_ r U� Specifications. <br /> I'I Public Ll Other 71 Delta Depth of Grout Seal S ITK'� D &r <br /> ETEmiA1*ype of Grout. <br /> I I tnigation Approx. Depth I 1 Eastern Surface Seal Installed by-C,'�11J FF Co AI <br /> Repair Work Done 13 Type of Pump H.F. State Work Done _ <br /> Well Destruction ❑ Well Diameter 1r Belling Material & Depth S!'t (i1 M <br /> Depth ;;L� 6 Filler Material & Depth ' r r r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it <br /> available within 200 feet.l <br /> Installation will some: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> _ Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest! Well Foundation Property Line <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 ordina <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permi <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub <br /> certifies the foil wing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to v <br /> tion laws of C ifornia." � <br /> The applica st call for all quired ins tions. pl'ete drawing on r 'Aa side. <br /> r f {} <br /> Signed x Title: �A �linfr>Lu / Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by c Date Area _ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ServicesJL7(.0 <br /> Environmental Health Permit/Services C <br /> 445 N Ban Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERK <br /> INFO <br /> EH t3-24(REV.1/na) i 3 •�-3 1 13- <br /> EH 4.26 <br />