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APR-05-1996 1103 MATRIX FRESNO 209'264 .02/04 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> BNVIRONYSNTAL RBAI'TH DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)468-3420 <br /> P O BOX 2009, STOCICTON, CA 98201 <br /> PERMIT MIRfi3 1 YRAR FROM DATE ISSUED_ <br /> (Complete is Triplicate) <br /> Application to hereby wwde,ta Baa 1*Rqu411 County for a parmtC to con.truet and/or ia•ta11 the Vark hereln described. This <br /> application to mde to caapllanee vlth Sao Joa4uln County ordlaaoce Ma. SL9 and 1062 arA the Mule• Sad MgUlatloas of San <br /> Joaquin County Public Health Servie"' ,,t _ . <br /> A /�L�I� — Ciry Lest S1 se s-.-ae <br /> Joh Address _ �•' K"- isw-' G^a"•rz '"r <br /> n 1 S.19 <br /> PhoneAddress - <br /> pwrwisNam• <br /> Cenpicta <br /> 1%) E --- •A:ACerev E License No.76S'sLC C!1 Phom - - <br /> TYPE OF LL/PUMP. NEW WELL 0 WELL PLACEMENT ❑ DESTRUCTION ❑ put of Service Well ❑ <br /> WE <br /> -- OTHER C3 Moal�inr W31 <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE U <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q tn. w trc ❑ open <br /> Bortom W <br /> O Manteca Dia.of p Excavation 1A a -- Ola. of Wap Casnq <br /> Jpt'Doms.ric Rivet O GnvN Pack '15:truy TVIa of Caainp PrC .5...__ ♦o Spanlica[ions <br /> 1'I Public \)a�bttw rl Delta Death of Grout Sees Tips of Grout <br /> — <br /> I I Initptgn .1_0 Approx. Dap[h I I Eastern Surface S.ut Instaued W <br /> Repair Work Done L7 Types of Pump N.P. Sista Work Dons `11 <br /> If Sexily Naterlal a Depth _ <br /> Well Destruction 0 WM Diameter "4 .Q <br /> Depth 76 f{' Piller Material i Depth C <br /> TYPE OF SEPTIC WORK_ NEW INSTALLATION I I REPAiR/ADOITION I I DESTRUCTION I I INo maim system permktad d public terref u .v rti <br /> CIVICnBANrKRch OF COMMERCE 39661 <br /> GEOMATRIX Oakland, California <br /> GEOMATRIX CONSULTANTS 100 Pine Street, 10th Floor 90-4095/1211 <br /> San Francisco,California 94111 CHECK NO. <br /> Consulting Engineers and Geologists <br /> 39662 <br /> DATE AMOUNT <br /> Exactly EWTY NINE Dollars and 00 Cents <br /> 04/05/96 $1;yfit89. 00 <br /> PAY <br /> TO THE SRN JOAQUIN COUNTY <br /> ORDER PUBLIC HEALTH SERVICES <br /> OF <br /> toe AUTHOHI2En SIGNATURE . <br /> Applicadon Accsotad b� Dale Alm6 L12 <br /> Pit a Grout Inspection by Date Final Inspection by Om - <br /> f 3 <br /> AdangRes Commence: <br /> Applicant - Return all copies to: Sao Joaquld County Public Sealth Services /'� D <br /> Savirodmental Realtb Permit/Services 95501 <br /> EV1 Q <br /> 445 San JOsquid, P 0 Dox 2009, Stka, CA <br /> R L {O <br /> EEE }tYOUNT O0E AMOUNT ftEM:TTEO CK RECEIVED 9y Ai PERMIT NO. <br /> NFO CASH <br />