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APPLICATION FOR PERMIT <br /> S*TOAQUIN COUNTY PUBLIC HEALTWERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1—JEAR PROM 12A3: LUX <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 Cotsplls.nce vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and 8egulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _ �, / Alcwx A— City57-;--1A1 Lot Size/Acreage � 7Sag c-• <br /> l <br /> Ir 0. ., _ /(�Gt _ Y. J �Oc-' �0-�Phone70 <br /> Owner's Name _ _ Address T 2 -3 /� rJy <br /> G <br /> f/ TR <br /> ( �1 QrS'D6 <br /> Conlractor �We44 ?V t 1I ►1 _Address ?Y �ewl f' Ucense Noa-7654 YOB Phone3���`>Z7'���j <br /> TYPE OF WELL/PUMP: -� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER a Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK tel- SEWER LINES -"-- / DISPOSAL FLD. PROP. LINE <br /> FOUNDATION -2:Z6' � AGRICULTURE WELL OTHER WELL ti PITS/SUMPS _ <br /> INTE OED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> In stn ❑ Open Bottom ❑ Manteca Dia. o1 Well Excavation Dis. of Well Casilw <br /> om fic/lIt ivata 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> P1 Xic is 011ier ❑ Delta Depth of Grout Seat ti�5~� Type of Grout CCr year 6r/- <br /> Ia jn Appro■. Depth © Eastern Surface Seal Installed by <br /> R air Work Done L7 Type of Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diam[e�ters Sealing Material i Depth <br /> Depth W4ft:Y f C<�S� - ^'� � tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION L1 DESTRUCTION C1 INo septic system permitted if public sewer is <br /> available within 200 last.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of livin4 unite_ <br /> 606 <br /> or table depth <br /> KEIIN S. t t-s�I+s t o <br /> >�EPIES Compartments <br /> LAbRIE D RIES USS 2� 19 �Y ad of Disposal <br /> 6801w SHEAVE CT. <br /> g1�3(GROVE' X58 Ie <br /> 3)3 -o o <br /> - <br /> p <br /> �l ct'-ro{r' _ <br /> ollars I. <br /> AItGE 1H -R , 4It I t 0 <br /> Mat <br /> bIST STItF�'E7 8k4;�' .. i� . . <br /> tAN1E CSA` Cf ._ r - �{ <br /> Mauin county ordinances, state laws, an <br /> POP— _1 'which this permit is issued. I shall <br /> or's hiring or subcontracting signatuf <br /> If MUCCI. I shall employ persons subject to workman's compensi <br /> 1 n• eppllcaM 'at carr all required inspections, Complete drawing on reverse side. C <br /> Signed t Title: iifo 0 o i 5 r �(,�c5f Date: <br /> J �� FOR DEPARTMENT USE ONLY F/ <br /> y� � �• <br /> fM-4 <br /> Application Accepted by Date _ . <br /> Pit or Grout Inspection fq�y� /Date Finaal,.lgope tion b Date <br /> Additional Comments: , + l N <br /> Applicant - Return..+,e4 co?Jas to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��"lb*t . t�CrJ�<'•d,L „-r�,+� 1• � <br /> jj. r'�'U ENVIRONMENTAL HEALTH DIVISION P1:RIIIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON. CA 98201FEE <br /> 7�' <br /> INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT NO, <br /> EH :4.26 <br />