Laserfiche WebLink
FOUNDATION AGRICULTURE WELL OTHER WELL Pirs/SUMP, <br /> INTENDED USE HYPE OF WELL PROBLEM AREA CONST"-TION SPECIFICATIONS <br /> ❑�Industrial J Open Bottom ❑ Manteca Dia. of Vvell Excavation Dia. of Well Ca+ <br /> Rt omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ..O-eta H.P._kT, 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if! <br /> available within 200 feet.) <br /> Installation will serve: 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 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 ordinan, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 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-c <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to wt <br /> tion laws of California." <br /> The applicant mu II for all require5 inspections. Complete drawing on reverse side. ��, ��`/////,,,'� <br /> Signed - I �— Title: ��[.�> Date: / <br /> �R DEPARTMENT USE ONLY / ,/ <br /> Application Accepted by Date ., �J5Area— <br /> Pit <br /> rea_Ph or Grout Inspection by Date Final Inspection by C' <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 /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT <br /> INFO <br /> + EEll 13-24 H 14-281REV.10/831 5e <br />