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<br /> rr APPLICATION FOR PESRMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> 3e ENVIROtd'UENTAI. HEALTH DIVISION
<br /> I 1601 E. AA7,ELRON AVE., PHONE (209)468-3420
<br /> P O BOK 2009, STOCKTON, Ch 95201
<br /> (COM016tri to Triplicstte)
<br /> FL AyDltertioa is hereby sma3e,to t:an JaaQuin County for it pemat to construct end/Or tnatall the vork herein descrtbnd. This
<br /> f Rppllettlob Is Made In CCWIiance vlth San Joaquin County Ordlnaue NO. $49 and 1862 and the Rules and Regulations.of San
<br /> J-111410 Coonty,Publie-Health 8eryleaa.
<br /> Job Address �r fi
<br /> ..r—�•.-� - .r.._ C+ry Lot Slea/Ac reweo
<br /> t r•balk` � s -: .:«.: '..- - ��� -
<br /> c,�`�4r Y i 6 _ Owners Name i�C -•f�Lu _ Address. "'t� f�_ ll � 5 Phona .
<br />' i �3 g sc yr Contratlor Address 1�p��'G5? 2Z•:'_8_'Llcente Hot" r �°Pnonr'
<br /> ar.
<br /> klH`. {}5r 'TYPE Of WELL/PUMP:- - ,NEW WELL ❑ WELL REPt_ACEMENT,[} DE ["]S7RUwTION Out or Service Well,-
<br /> PUMP INSTALLATION ❑ 'SV57KVt AEPAIR,❑ OTHER ❑ l7onitorirfa Well.:Lj.
<br /> DIS A4CE TO NEAREST SEPTIC TANK ' SEWER LINE5 _DISPOSAL FLO P. 0 LINE
<br /> FOUNVATION" AGRICULTURE WELL OTHER WELL PITS SUMPS y�1
<br /> ; # "INTEND t1,eF TYPE OF WELL PROBLEM 4AVA CONSTRUCTION SPECIFICATIONS'•
<br /> a•'• x �1 Indwtkrel.. :❑Open Bottom.. ❑Manteca' Oia,'of Well,Fa<aveti fn ;Oia.of WWII Crs,
<br /> I Come
<br /> i W t
<br /> e•. �ft-Gr vel P
<br /> eek '.'f).Ttaev :_. Type of Caasnq peedlcatlans ,.
<br /> +'y< Ni t I I Pubik -'C7 Ottar s s Il Odla p
<br /> Deth of Grout Seat--
<br /> '.' Tye Of Grat;f
<br /> Eastain ;Suriate Seuf EnatalHd by' `
<br /> Work tor» U Type of Pump H P. .;.- State Work"Oona
<br /> V�es Deatrucfir t Q Wall D, rater &fauns srterlal i Depth t 1
<br /> S 3T rr ti r A, uDID
<br /> >4-'" r s-;� ,3 y `--OeplA `' .. '.Filler.Yaterlal'i'DepLh + y !
<br /> -'.. -
<br /> TYPE OF - TIC WORK r NEYt INSt LATION 1 1`REPAIg1ADCITIO DESTRU ,IUN t I INC sentic system permitted it pi,Wko-wwef
<br /> i avaitable within 2W feet) -
<br /> z is M ik y tnstattaeon wig serve 5 R"Wence -Cornmerelai.:_
<br /> f' F S 9x-Number of livrrg un tsi`��.;.Number of bedroom:
<br /> aractalr of'go tout doth 13 feel 4 D077,e 6.GSA•ti •Wetir tabM deDfh "� + u � {io!
<br /> .r�fpPr'TANK�kr ,•.V Y�',O j'Type/M117 ' L' CapaClfY �No 'C'Onk` rlrtfenfa I`"" , ,, r r r� 3t'P '
<br /> fPKO 4 REATAI•v 1'LT�❑ r4 r + 1. Mathod of 01 +
<br /> OEstenee to nearest Wall Foundauan Property Llne a^r r
<br /> �,:., ,i -
<br /> # EACFIINCt LIME /�y--
<br /> " ,cam 140
<br /> '&'Length of lino 7 oral:length/sue 4�" g ' r F l.z Q.
<br /> ` FIl 7ER{8ED [,i L7 `
<br /> s pistontC
<br /> neeNet
<br /> _�d Foundatwn�4 Propr'ty Lllw � �, tk t f irq
<br /> • � tY�a1l Fx1,lL CY.�F�a wV':kl ,, �A t �ar+ Y - .',: � •:c,..:": t -:-. +I _ _ � t� �}F'of�,,,*��� �'� �
<br /> r , aSEEPAGE;PITSIz'
<br /> 1�Sue
<br /> l�XLS{JINPS.'�`f. S rr Dist nce to nearest WNI r 1 Fourdatlon
<br /> r I$ OSL PO�1D5t fit:❑ y�pi .,.R a�r}.,'' ' art;'- , .,,i :,.- r to t i £ t,..,4 eft .> v t
<br /> r rR
<br /> ' } ..,, �t`I:tferslfy'errttfy tlsat!hwe pripared this+rppkkatlon and that the work wI I be done in acLordagce w,th San Jwquin.cdunry ordidancef stats taws and
<br /> :. } trulea and,regirtatbrks of the 5sn'Jaquln'Coiinty; h . rl�k r i0
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<br /> L ,raX 'y Hfirrie owner's IlceneaQ atpsnt.s"etpna[tue wnffias tha,following I cinify Chit,n the.pariorrrenei,of-14 work}orlwhkh this permri i lswed,t'shall not� f
<br /> �� ""-��'+• ertikpfOY'�nY pvsa)s In sireh mehAAr ea to-became wbjeet to warkman's'cortipensmion raws'of Cilliforrl.."•ConlrfcioCs hiiing'ok.wDv:�fncdnq!{prature
<br /> ff_CeAfliM�the`fOKowing:,'9 Cartify that rn the perttxmanrr of the work.tar wh!eh Ih s permit Is luwo I Malt 6n,;..•)cy persons subject to workman■campeniasi; _s
<br /> +e r.t,*Iorl taws o1-Wlliornla ? .� a; .> �,•,, , f ,. ,f s r
<br /> YM�ipplf�akAt,muet cag for on r n t
<br /> ex=uItsdInaWef{ono Comptata drew np on reveno side
<br /> Cd4 Yr} S l(rt�1M')' I`a 4�'` -Y i- ,i -, _ +ro 1 •• I
<br /> ,�._ `i# It 4} r r i.711N
<br /> pr.•� " g1 / i a �f 5 }F,i } r EOR CEPARTMENT USE_ONLY i
<br /> $LA�r�'-t•.:"Yk a 'l"Y'"Y' '3• '�`• d - ( -:nit i k-r�.y �s +u Grr �r�`rj� .,i a-+ :,�
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<br /> r Yi,rnppl}i„r�tlon�, ttested by}Y Cato
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<br /> ry s+.a S Pk rxa6rout Inapeetfan by r'pate ' Final Inapecdon by't
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<br /> Vqy q'r Appllcaa 1lrture �.l.l copLaeJ to 61aa Jtaaquia Cewity:Atblic itewl th q t --:?z i Y -'r r i +?" " air r= - -r'
<br /> ,-.�.' $y.i :, �'�yr. r7 'Berri eee ,EnyironMental Raalth Perm t/Serrleee ` "1 ' ' -a
<br /> 1601
<br /> �,� s S �r ak��' .�<�¢ ,}I r :,• L F.aseltoa-Are P 0 Box.2l)09•'{BtioCltten, G1`+-95201 ' r.--" +^� �I I rt ts� •:n {„ �
<br /> FEE AMOUN7DUE rs : 4. AttOtJ1J7.REaAtTTFPtf i CK- L t'.?'RFCEIVEDlY t :.r,-, OATLT ►fRM1T HO+.� �'r 1'lytirr'
<br /> '•. INFO -CASH {r-. - r Z
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<br /> twlaalr C+��p{,.' t rtY`t $
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