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FEB,15 '95 04:04PM FUGRO NEST ROSEVI6LfLICATION P 2/2 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SMICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P . T ESPIMS 1 YEAR FROM DATE ISSUM) <br /> (Complete in Triplicate) <br /> Application is hereby nada to Sao Josqulp County for a permit t0 construct and/or install the vork herein described. This <br /> application is Bade in eomyliari with Sap Joaquin County Ordinance No. 549 arks 1862 end the Attlee end Aegulatlobs of San <br /> Joaquin County Public Health SeLr,►lces. / <br /> job Address 7—�?J `�Un- 'f%e (�c/,� ✓O Gty i Lx- � Lot Size/Acreage <br /> Owner's Name �'" �" / / Address �U YCIK.yr/• ��•-f/nCn!-i/ C ZL'} Phone .67Z­4M�6 <br /> Contractor 6Lerg�Ln p'L4 Address SSL r1C••JC �E,(a/✓Iw-t�oltL License No t7� 4L.°"�l�spn�nl �13- 1In <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION a Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER rJ Itonitorlttg Well ❑ i <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE { <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 71 Industrial p OOan Bottom ❑ Manteca Die, of well Excavation Dia, of Well Caring <br /> M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CaSrng_ Specifications- <br /> ('I Pulak 17 Other fl Delta Depth of Grout Seal Type of Grout. <br /> I I Irrrguton _Approx, Depth I I Eastern Surface Saw Installed by <br /> Repair Work Done U Type of Pump R.P. Stat Work <br /> WlII Destruction ;9 W-00 Diameter Sealing Material i Depth w j <br /> Depth 'filler Materia_ i Depth <br /> 4i 7t.•f C11 ft-5• <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t DESTRUCTION I I (No mom system pem,tied if pudic sewer U <br /> available within 200 leat.1 i <br /> Installation will seM: Residence — Commercial _ Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 toot: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capachy No. Comtertments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal , <br /> Distance to merest; Well Foundation Property Lina <br /> LEACHING LINE ❑ No. b Length of lines Total length/sire <br /> FILTER BED ❑ Distance to merest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sirs Number <br /> SUMPS LI Distance, to merest: Well Foundation Property Lira <br /> DISPOSAL PONDS ❑ <br /> I hereby cartily, that I have prebared this application end that the work will be done M accordance with San Joapuin county cromances. stag taws, and i <br /> rules end regulations or tits San Joaquin county <br /> Horm owror or licensed agam's signature certifies the following: 'n comfy that In the PapiOmtance of the work for Which inie permit Is issued, I shelf riot <br /> employ any person in with mannas as to become subject to womman's compensation lawn of California." Contractor's hiring or sub-contrectino signature <br /> Canifles the,toNowing: -I Canlfy that in the performance of the work for which this permit in issued,I shall employ persons subject to workman's compenes. <br /> line,laws of Califoryl <br /> The applicant�t\w+t call Icer 1 w inrpectlnris. Lampvia orawino on re arse Side. <br /> Signed X 4 !��1 Title: t Date: <br /> FOR DEPARTM& USE ONLY <br /> Application Accepted by Date Ares <br /> Pit or Grcur inspection by Oats Final InspaCdon by note— <br /> Additional <br /> atsAddition l Commemr: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> £eviroomental Nealth Permit/Servlcee <br /> 445 N San Josquln, P O Box 2009, Stan. CA OS201 <br /> INFO AMOUNT DUE AMOUNT REMITTED C SR RECEIVED BY DATE I- ho"'NO. <br /> Page 13.4 <br /> w r4f � <br />