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JAN 17 '95 05;23PM FUGRO WEST ROSEYILLS P.2'`3 <br /> APPLICATION E r <br /> STAN jowim GOiBirl'g PUBLIC ZRAT TH SERVICES <br /> IMIRONETAL ZRALTR DIVISION <br /> 44S N SAN joAIUIN, PROM (209)468-3420 <br /> p O WX 2009, $Ti9CST0N,' CA 95201 <br /> FROM DAT <br /> (Complete in 'Triplicate) <br /> Appitestion is hereby Mde,to $art Jcaquia CountY rpr a permit to conlftrwt and/or install the cork herein described. Tbir, <br /> agpiieation is ode is compliance with Sea Joaquin County Ordinance No. 549 and 1862 and the Rules mud Re-rilationa <br /> n0Of& <br /> JamcpLa Couneyr Public Health-8ervIces. <br /> .tob Redress 2 <br /> City �"` Zfx Lot size/Acreage <br /> Ovrrnar's Nem irr , <br /> R ` �ek.hi�n PhI� q 6�30 1 <br /> ConlraGf4r +# ll - rrlh Address k lcense No.4-971ZAL9 Wid <br /> 2t <br /> pho d <br /> ME F WELLIPUM : NEW WELL WELL REPLACEMENT Cl QE9TRIICTICSfJ Cl but a! it-Or&8GTvia "ll <br /> Ia <br /> PUMP INSTAL Lr Tf SYSTEM REPAIR .❑ OTHER U Lif'prt Weil AT <br /> DISTANCE rD NEAREST: SEPTIC TAMC - SEWER LiNES 0 DISPOSAL FLO> PROP, ZINE <br /> IrovNtwnON AGRICULTURE WELL7-622& OTHER WELL PIYSISUMPS <br /> INTeNDED UBE TYPE OF WELL PRQS_LEM AREA CONSTRUCTION SPECIFICATIONS ,r <br /> M mdustriai ❑Open Bottom 0 Marneca Dia. of Well Excavation . <br /> ` Die. of Wag Cesing i <br /> C.I DornasticlPrivate Q Cdavel Pack ❑TracY 'type of Casings � � Speeificalkws � <br /> l'1 Public }lit ptlrFr t F1 001a Depth of Grow Seat _ Tvw 41 Grout <br /> I l Irrigation �4prcx. Depth I 1 Eastern Surface Bout Irwtalk"by <br /> Repair Work [lone 'U Type of Pump H.P.�-�" Stat4 Wapt Do ryB� � 4 I <br /> WYII tian ❑ Well Diameter4`d sealing Material i Depth �_�!- iF� ��r► D� �� �.� G��C.rT ��'F <br /> Depth " 1' - Fiber itlstlh`!al i Depth <br /> YYPE OF SEPTI WORK: NEW -fSTALLATION i I REPAIRIAODITION I 1 DESTRUCTION I I INo w0kc syatam pfrntitud if public atlwaf is <br /> available mathin lob loet.I <br /> instaliation will servo: Residence— Cotnmercial— Other <br /> Nufnbef of living units: Number of bwroams _.�.- <br /> Chmacler of soil to a depth of 3 fleet._ - Water table depth <br /> SEPTIC TANK ❑ TV"fMiO Capacity- No. Compartments <br /> PK(I.YAPATMENT PLT.0 Method at Dia*a asol <br /> Distance to newast: Well_ Foundation Property Lute _ I <br /> LEACHING LINE CI No. S Length of lines Total Iertgthili:e <br /> F[LYEfI DED CI Distance to neereat: Well Foundation----- - Property Line <br /> SEEPAGE PITS I I Depth Sias Number <br /> SUMPS Irl Distance to noormat: Well�� Foundation Praperttr Line- <br /> DISPOSAL PONDS a <br /> I homby oerdfy that I have prepared this applicatiiw and That ohs work will be done in accordance with San Joaquin county ordinances, state latus, and <br /> cafes and fe"liafls of the Sen Joaquin Co=%V I <br /> Hama ownat or Iirarwo&pant's f;Ignaturg cortifiya the foliPwing: "I certify that in the performance of fha work for which this psrnvt is issued, I ahiti not I <br /> employ any person in such manner as to bwarne olublev'tc workman's coHV n99tk;rt laws Of California."COM0111 t0fq hiring at glib-COTrirscting sfgnaturB <br /> ear4tfiell the following:11 certify that in The pertormfunce of tits work for which this permit is ismel,I shall amptoy persons ttttbjsct to worknwn's Cornpefuis� <br /> tion laws of Calfofnls." <br /> The applicant from calf far all requited lnspgctlans. GOmptete drawing an ntwww side. I <br /> S4ned X Title; GL.0Raley` j,1$-21:c <br /> FOR pEPARTMRNT USE ONLY <br /> AppOntion A g II by Date 1 U i Area _ <br /> Pit or Q1Wt Imontioft by GI'ia final InspeCtion by Daft <br /> Additional Commsftts� <br /> appiiekni - Return all copies tat San Joaquin County Public Health Services <br /> Esvironelrrtitai Health ParmitJservioea <br /> 445 N San Josqutn, P d Box 2009, Stkn, CA 95201 <br /> F€€ AMCXMT OUE AMOUNT REMirrED CASH H IaECElVCeO$M DATE PERMIT'NQ. <br /> INFO / f j}1E MI <br /> Gtr 17.21 MIN.tj■% �. �� � Akc.Cr-�1 J � le)' bc) ✓63 <br />