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INTENDED USE . TYPE OF N%ELL PROBLEM AREA CONST➢'OCTION`-SPECIFICATIONS -. <br /> ❑ Industrial . Open Bottom ❑ Manteca Dia, of . .,I Excavation.• Dia. of Well Ca: <br /> ❑ Domestic/Private 11 Gravel.Pack. ❑ Tracy Type of Casing Specifications <br /> ❑ Public - El Other, ❑ Delta Depth of Grout Seal Type of Grout_ <br /> ❑ Irrigation Approx. Depth Q Eastern Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump H.P. State Work Done <br /> _ Well Destruction ❑ Well Diameter Sealing Material (top 501. <br /> Depth Filler Material (Below 501 <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION O . REPAIR/ADDITION' 'DESTRUCTION ❑ (No septic system permitted if p <br /> available within 200 feet.) <br /> Installation,wall server Residence '`Commercial Other <br /> Number ofliving units: Number of bedrooms .___` <br /> Character of soil to a depth of 3 feet: ° ,i Water table depth <br /> SEPTIC TANK W Type/Mfg A `I,LA� apecity 0112"k No. Compartments <br /> PKG. TREATMENT PLT. ❑ �� ' Method of Disposal <br /> Distance to nearest: Well ✓ Foundation%&70'4" Property Line bZ� <br /> LEACHING LINE No. & Lang th of � <br /> Pnes �—'y0 faT - Total length/size !�6 77— <br /> FILTER BED ❑ Distance to nearest: Well�rFoundation SD PT Property Line <br /> r SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 ordinanc <br /> rules and regulations of the San Joaquin Local Health District:': <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workJor Which this permit i <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-cc <br /> �- certifies the following: "I certify that in the performance of the work for which this permit is',issued, I shall employ persons subject to wo <br /> tion laws of California." i , <br /> The applicant must call forall quired ' spections. Complete drawing on reverse side. , <br /> Signed X MalA Title: it Date:' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �`� w s�'� Date 17(0 Area <br /> Pit or Grout Inspection by Date Final Inspection by �04,t/.% �,n <br /> Additional Comments: - - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835;6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 . azelton Ave., P.O. Box 2009,Stk.;, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE ' AMOUNT-REMITTED CASH RECEIVED BY -- DATE - - - PERMIT <br /> t EH 18-21 Ia EV.t <br /> EH 1429 <br />