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JAN 17 195 05:23PM FUGRO bE61 RU!_+_V1LLL <br /> AppLI C.A7''I ON <br /> BAN JOAQUIN COUNT' pUBI.IC HEALTH SERVICES <br /> ENVIRONMENTAL KULTR DIVISION <br /> 445 N BAN JOAQUIN, pHONB (209)96801420 <br /> p 0 AOA 2009, STOCKTON, <br /> e^u�IT >�XVIRFB � Y� FRAY DATF i Ss uSD <br /> (Complete in Triplicate) <br /> her <br /> in <br /> ApPlieAtifill to pplieAtdop So sadebidmcddo-sa Sm elthuSon Jeapuln COWLp Orddin ncecounty f" a permit o ngo. 549 andotruct O1862 and the Rules andeReetslationedof lsane� <br /> 1? ,OPG-q <br /> JlaaQoiq County Public Eeal)tlt.Retviceate.. "— v <br /> Lot Size'-- <br /> ti <br /> City <r <br /> Job AddressEr /� � �y+ <br /> ycr5.•�Nn Phan( <br /> • • c„G AAdrass <br /> Owner's No ".H/r^ <br /> 91t- •i Ii�rY'1 64r r'& r9 CN'Z6gE Pho G '7 <br /> Cswyicn well <br /> mhacipr <br /> Well <br /> f) f; rJt atldress License No.L <br /> F WELL"PUM : NEW WELL WELL REPLAClMENT n DESTRUCTION 0 Out Ifonl lnring Well <br /> AT <br /> SYSTEM REPAIR C OTHER O �/� <br /> PUMP INSTAL TI C(� DI6POSAL FLD lU1J PROP. LINE r4• <br /> DISTANCE TO NEAREST: SEPTIC TANK �l SEWER LINES >io <br /> '�— FOUNDATION 3/_2' AGRICULTURE WELL7/WA OTHER WELL-24-0— PITS"SUMPS <br /> INTENDED USE TYPE OP WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> Ll IndustrlN 0 Open Sodom <br /> Mam6Ca Die. d WNI Eaooeation Die. el Well Cssktg <br /> Ty Of Casi:0002_ t U v• TypeSpecf Grout f I <br /> Domestic/PNvate O Caravel Pack ❑'Rsev Troy of Grout <br /> I'1 Public y� r fl Dale Depth of Grotrt 9eN <br /> 9 <br /> I I Initiation �r�7,Approx. Depth I 1 Ebtem Surface Soul hretatbd by r w r � <br /> T of Pum H.P. -��"" /Stel�Wgrk UC� ^� Z-. Ce <br /> Repair Work OOn! U YPe p " Sealing Rateeial L Depth Mfr '4,P r`^C. •r' <br /> WNI_Dfetjuctinn n Wall Diameter <br /> ,�_ <br /> /1/ft Depth '�7 Piller Ikater/<1 i Depth <br /> y TIC WORK: NEW INSTALLATION I I REPAIWADDITION I I UESTRUC510N I I lut. �. ... IF iorthin lined it pontic 6xx ver is <br /> Inttalietion wing serve: Residence— Commercial — Other <br /> Number of living units:__ Number of bedrooms <br /> Water table depth <br /> Charoclor of soil m■depth of 3 het: N0. CWrWa n4 <br /> SEPTIC TANK O Treatmig Capacity <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ <br /> Distance to naareaL' Well Foundation Praporty Linc <br /> LEACHING LINE ❑ No. E Length of Knee total lengthisize <br /> FILTER SED Ll Diatence to 41041061: Wo Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sim Number <br /> SUMPS LI Distance to rearm: Well fOundation Property Luta <br /> DISPOSAL PONDS O <br /> 1 hereby cartily that I hove prepared tits epplicotnn and that the work will be Iona in accordance with San Joaquin county ordinances. sole laws, and <br /> rules and regulations of The Sen Joaquin Count? <br /> Home owner or lic read agent's Ngnsture oarlifye the following. 11 certify thir in the portorm1111109 61 mo work for which this perusal is issued. t shall not <br /> employ any person in such rrllnner as to become subject to workman's comrerrzetion laws Of CalifOrm4.-' COntraCtOrj irrig of sutrcontrec ling signature <br /> ip <br /> coni the IOlbwing: "I Certify that in the poincrmarrce of the work for which this permit is issued,I shall employ persons bjeal 10 Workmen's Compenp, <br /> tion Ism M CaliforrIM." <br /> The spplicutr mus,sell for aH requited inspactions. Complete drawing an rsvena side. <br /> Title: <br /> nPl/_rsZ D9M; -18'9 <br /> FOR PEPAEITMENT USE ONLY vr^� c <br /> tj <br /> Apptleation Accepted by <br /> Date I U C1 J Area J <br /> Ph w Grout Inspection syData Find IMention <br /> eF 1111 rt by Dale <br /> Additlonel Comments: /W-3f <br /> applicant - Return all copies to! SnvironnentaloEealehuPOrmit/Sarvle90 blic flealty, ieea <br /> 445 R San Joegnln, P 0 Ron 7009, Stkn, CA 95201 <br /> FEE AMOUNT 0VE AMOUNT REMITTED Cx RECEIVED Ev DATE PERMIT NO. <br /> INFO CJS/N /. r'1 1y1�Q <br /> . Ca IMM <br /> In".Ire 1r C� 1 (:MM? ���`��J/ ` ��/. 1 s D� ��� <br />