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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> L� ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I � ,/ <br /> Job Address tia�j C "��-^ Ciry�os /� Lot Size/AcreageNlSus0 Xltu iV <br /> Owner's Name P!1.,.�¢`� / T�.Lw.7 r.,. Address C L, Lbw / Phone c J d <br /> M,,IeAj , C(8 t153 3 <br /> 3J17 Se r:r...J , e L <br /> Contractor Address c..::-....4, ca. yS.ft 4, License No. l...Vd� Phone9lb{ (51-Sdoe <br /> —� --- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1❑ OTHER 19" Mpnitoring Well 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7`" (SEWER LINES<141DISPOSAL FLD7�'/ ` 7 r"�` ".',dA <br /> _SI 1 V�~ <br /> PROP. LIN ,"h-- )$ <br /> FOUNOATION4SFF->I's!l AGRICULTURE WELL'7S': rL OTHER WELLZ3'- PITS/SUMPS';2,L-9!)- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l <br />