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FOUNDATION AGRIUULIUHC VVLLt. — "I 1 <br /> INTENDED USE HYPE OF WELL PROBLEM AREA CONSTP TION SPECIFICATIONS <br /> Industrial Open Bottom ❑ Manteca a. of Veil Excavation Dia. of Well Ca <br /> ElDi <br /> ❑ Domestic/Private EI Gravel Pack C3 Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler MaterialBel <br /> ( ow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it <br /> available within 200 feet.) <br /> Installation will serve: Residence ! Commercial _ Other <br /> Number of living units: ---/ . Number of bedrooms 'S <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> y LEACHING LINE No. & Length of lines _ Total length/size .� <br /> FILTER BED Distance to nearest: Well F�ou. atiQ_n Property Line <br /> SEEPAGE PITS I I Depth Size DO �� Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> _ DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinar <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 work for which this permit <br /> .. employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-1 <br /> certifies the following: "1 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 /> The applica mus c��'1–f�ry5,r all required inspections. Complete drawing on revers e. <br /> Signed K � ✓ 1 ��"'�' Title: ^`��� Date: <br /> OR DEPARTMENT USE ONLY <br /> 1 Application Accepted by / Date V f� Area <br /> Pit or Grout Inspection by ate Final Inspection by <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 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI <br /> NFO <br /> . EH 13-241REV.1/x51 ���� `7 ,V� ��14� S7- <br /> EH 1479 <br />