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FEB"15 '95 04:02Ptl FUGRO LEST ROSEVIILLLE ICATION P.2/2 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SLICES <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQIIIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCXTON, CA 95201 FEB 1 <br /> PEMI:[ EXPSRE3 1 YEAH FHOIS DATE I55 , <br /> (Complete is Tr ate) .. <br /> Application in hereby msdt.20 San Joaquin County for a permit to construct and/or tnetau the vork herein described. This <br /> app]Soatl.0u in Male in compliance with 9azi Joaquin County Ordinance Bo. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Seryic"- /7 JI i- <br /> ZS75 4- L/17 IK(IJIJ Clry f �pTuVl Lot 31 re/Acreage <br /> Job Address 417 ��; <br /> (/. Aadresa <br /> FG Bax 4P" L(1 nGr) �/` q 1'i ZL 1 Phone �7 E16� <br /> Owner's Name, <br /> J� - . <br /> G e�, 1/. ; n ti Address �� "PL1�ense No.C>7 tt?7 I LS Pnnec)313—>SOS j <br /> Conuacmr – <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION Q( Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER G Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Dia. of well Excavation Dia. of We" Caning <br /> Industrial O Open Bottom O Manteca <br /> CI Domeetrc/Private ❑ GravN Pack O Tracy Tyoa of Casing_ Specifications <br /> t'1 Pllblit 1-1 Other f] Delta Depth of Grout Seal Type of Grout <br /> I I ImBstion ,AoPtOx. Depth I I Eastern Surface Saw Installed by ' <br /> Assail,Work Dors L] Type of Pump H.P. Stat work pna - <br /> WaU Oagtnretidn [,B{ <br /> Well Diameter Sealing Material a Depth <br /> Depth Piller Material i DeDch Y_c:Stu rP- rr/A✓I / !' lz. �--�ts'.�t,¢��ILG /-i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i DESTRUCTION t I (No septic system permitted i( Public s~ is <br /> available within 200 seat./ <br /> Instigation will some: Residence — COMIMI Clel <br /> Number of living units: _ Number of bedroomr <br /> Character at wit to a depth at 3 tees: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compenmenn <br /> PKG. TREATMENT PLT. O Method a1 Disposal <br /> OLstance co heartst: Well Founenuon Property Line <br /> LEACHING LINE CI No. 6 Length of lines Total length/size <br /> . FILTER BED ❑ Distance to neeresz: Weil Founoaten Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Oivartca to neerMY. Well Foundation Property Lia <br /> DISPOSAL PONDS ❑ <br /> 1 hereby Certify that I have prepared this application and that the wwk will be done in accorcance with San Joaquin county orcirences. state laws, and <br /> rules and regulations of the San Joaquin CoNity <br /> Home owner or Incensed agent's signature urttfes the following: -I certify that In the performance of the work for which INS permit K issued, I shell not <br /> empty any person in such martyr as to beroms wblect to wonimon's comolnnation laws of California." Contractors hiring or sub contracting Signature <br /> certifies the following: -I carltty out in me performer"of the work for which this permit is issued.1 shall employ parading■ubpct tq workrtten's Compensa- <br /> tion laws of California." <br /> The applicant must call for r..rrl��1IIjr iincpecloci Compete drawing on av ns side. _ <br /> Signed x \04 0.'1 - Title: I I Dau: <br /> FOR DEPARTU T USE ONLY <br /> Application Accepted by Data Ana <br /> PN Or Griot InapeCtldl by <br /> Dace Final Inspection by Dote <br /> AddhlorW Comments: <br /> ADPli Cant - Return all eePies to: San Joaquin County Public Health Service. <br /> Envirouoental Health permit/Services <br /> 445 H Sae Joaquin, P O Box 2009. Stku, CA 952D1 <br /> FEE AMOUNT DUE AMOUNT REMITTED' CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO .P[Fge X <br /> EM INp IaEv,v a a I <br />